Abstract
BACKGROUND
Social determinants of health are a well-described influencer of pregnancy-related morbidity and mortality. It is unclear how societal changes secondary to the COVID-19 pandemic altered the social determinants of health among pregnant patients.
OBJECTIVE
This study aimed to investigate differences in the social determinants of health among patients who experienced pregnancy before and during the COVID-19 pandemic.
STUDY DESIGN
This was a secondary analysis of an ongoing prospective cohort study examining the social determinants of health in postpartum patients at a single inner-city academic medical center. The planned secondary analysis was to compare the social determinants of health between patients that experienced societal changes before the pandemic and patients that experienced societal changes during the pandemic. Patients were included in the pandemic group if they delivered on or after March 30, 2020; moreover, patients in the pandemic group were compared with those who delivered before March 30, 2020 (referent group). Medical records were used to collect sociodemographic, pregnancy, and infant outcome data. The study participants were interviewed to collect detailed information regarding their perceived social, emotional, and physical environment as indicators of social determinants of health. Generalized linear modeling estimated the influence of social determinants of health on births during the COVID-19 pandemic.
RESULTS
Overall, 577 patients were enrolled in the study, of which 452 (78%) delivered before the COVID-19 pandemic and 125 (22%) delivered during the pandemic. Patients who delivered during the pandemic were more likely to report limited social or emotional support (relative risk, 1.62; 95% confidence interval, 1.02–2.59) and higher race-based discrimination (relative risk, 1.59; 95% confidence interval, 1.00–2.53). Mothers in the prepandemic group were more likely to have used federally funded programs, such as Medicaid, food stamps, and the Special Supplemental Nutrition Program for Women, Infants, and Children, during their pregnancy. Furthermore, the referent group reported more limited access to transportation. In addition, mothers in the prepandemic group were more likely to initiate prenatal care at a later gestational age and have fewer total prenatal care visits.
CONCLUSION
The COVID-19 pandemic created unprecedented changes in pregnancy care, and these were reflected in social determinants of health. It is imperative that we focus on the social determinants of health that were mitigated during this time and their effects on maternal and infant health.
Key words: access to care, healthcare equity, perinatal morbidity, racism, safety, social determinants of health, transportation
AJOG Global Reports at a Glance.
Why was this study conducted?
This study aimed to determine whether the significant changes to our healthcare system and society during the COVID-19 pandemic influenced social determinants of health.
Key findings
In our cohort, there was increased access to prenatal care and transportation during the pandemic; however, patients also experienced more discrimination and noted less social and emotional support during the pandemic.
What does this add to what is known?
Not all changes during the COVID-19 pandemic were negative; however, the pandemic highlighted the growing disparity in the lack of support for inner-city patients and the importance of identifying areas for resource allocation.
Introduction
Social determinants of health (SDoH) are the conditions of the environment where a person is born, lives, works, plays, learns, and worships that manifest in a person's health, functioning, and quality of life.1 SDoH can be grouped into 5 domains—economic stability, education access and quality, healthcare access and quality, neighborhood-built environment, and social and community context1—and addressing disparities attributed to SDoH is necessary to increase equity of healthcare among all. The COVID-19 pandemic exposed many of these persisting drivers of health inequities, as demonstrated by the disproportionate burden of disease on a range of populations, including pregnant patients.2
As of the time of the study conclusion, more than 79 million confirmed cases of COVID-19 had been documented in the United States, more than 225,000 of which were in pregnant patients.3,4 Prasanna et al4 demonstrated higher positivity of the SARS-CoV-2 polymerase chain reaction test in pregnant patients who are younger, have higher parity, have public health insurance, have lower education attainment, belong to minority racial and ethnic groups, have lower English proficiency, live in low-income neighborhoods, and have larger household size. This implies that SDoH play a significant role in the risk of COVID-19 in pregnant patients; however, it does not explain how the pandemic, as a whole, especially the societal changes that came about secondary to the pandemic, influence pregnant patients. Thus, this study sought to evaluate the changes in SDoH in an obstetrical population during the COVID-19 pandemic to better understand how these societal changes might affect pregnant patients and their newborns.
Methods
This study was a secondary analysis of an ongoing prospective cohort study with data obtained from 577 postpartum patients at the University of Cincinnati Medical Center between 2011 and 2022. The initial study was created in 2011 to evaluate SDoH among pregnant patients of Hamilton County, Ohio, in an attempt to improve maternal and perinatal morbidity and mortality. The survey for the study was constructed with questions assigned to one of the categories outlined by the World Health Organization.5 The survey has a total of 192 questions and 64 demographic and outcome variables encompassing the categories: physical environment, social environment and protection, health behaviors, healthcare, and structural drivers. A blank survey in its entirety can be found in the Supplemental Materials. Patients were recruited into the study through daily rounds in the postpartum unit. The eligibility criteria included patients aged ≥18 years or <18 years with parental consent. Patients unable to give informed consent were not offered participation in the study. Patient medical records were used to collect sociodemographic information and maternal and newborn outcome data. Participants were interviewed by study personnel using the aforementioned survey to assess the patients’ perceived social, emotional, and physical environments to evaluate their SDoH. Survey responses were captured and stored through a Research Electronic Data Capture, a fully Health Insurance Portability and Accountability Act–compliant platform, which allows for deidentification of patient information. No compensation was provided for study participation. The original cohort study was approved by the institutional review board at the University of Cincinnati (IRB number 2013-2443), and after the pandemic began, IRB amendment was approved to include an analysis of frequencies of SDoH before and after the pandemic.
The primary exposure variable in this study was pregnancy during the COVID-19 pandemic, and given that the state of emergency for the COVID-19 pandemic was declared on March 13, 2020,6 the selection criteria for the pandemic group included patients who delivered on or after March 30, 2020. The referent group included patients who delivered before March 30, 2020, and this arbitrary date was chosen as the cutoff as much of the rollout for new patient care happened in the month of March and, therefore, would influence subsequent pregnancies and deliveries. Here, the primary outcome variables were the following SDoH indicators: living conditions, social support and protection, joy or resilience, healthcare coverage, healthcare utilization, intimate partner violence, and discrimination. Living conditions were evaluated by household size during pregnancy, with ≥5 persons considered a large household size, and by number of moves, evictions, or periods of homelessness during the pregnancy. Patients were categorized as having low joy or resilience if they responded to the following question with the 2 most negative responses (less than moderate) on a 5-point scale: In the past year, what is the average level of joy, happiness, or contentment you felt? Utilization of healthcare was defined in terms of limited prenatal care during pregnancy (<5 visits) and delayed or late first prenatal care visit (after 14 weeks). Intimate partner violence was defined as answering “yes” to either of 2 questions asking about experienced physical or verbal abuse during the patient's most recent pregnancy. Discrimination was defined as answering “moderately” or more frequently to a survey question asking if the participant felt that they were treated in an inferior way because of their race, skin color, or ethnicity. Assuming a baseline rate of 25% of various SDoH, with a study group of 125 patients, we would be powered to detect a 10% difference between groups.
The secondary outcome variables included pregnancy outcomes and adverse newborn outcomes based on birthweight, gestational age at birth, Apgar scores at 1 and 5 minutes, and abnormal conditions of the newborn and congenital anomalies of the newborn. The pregnancy outcomes captured included weeks at the first sonogram, gestational age at the first prenatal visit, and total number of prenatal care visits. Low birthweight includes newborns weighing ≤2500 g. An Apgar score of <7 at 5 minutes was considered low. Abnormal conditions of the newborn included, but were not limited to, assisted ventilation immediately after delivery, neonatal intensive care unit admission, newborn given surfactant replacement therapy, antibiotics received by newborn for suspected sepsis, seizure or serious neurologic dysfunction, and significant birth injury. The list of congenital anomalies included neural tube defects, cyanotic congenital heart disease, congenital diaphragmatic hernia, gastroschisis, cleft lip or palate, trisomy 21 or other chromosomal disorders, and hypospadias.
Baseline maternal characteristics, including sociodemographic factors and pregnancy characteristics, were compared using the χ² test and Student t test as appropriate for categorical and continuous variables, respectively. The frequencies of various SDoH were compared using the χ² test, and a generalized linear model was used to estimate the relative risk (RR) of SDoH on births during the COVID-19 pandemic. No adjustment was made to RR modeling as risk modeling adjustments in studies of SDoH are both uncommon and difficult because of the significant overlap with the various social, societal, and economic factors, which can influence a patient's health. Results with a P value of <.05 and a 95% confidence interval (CI) not inclusive of 1.00 were deemed significant. Statistical analysis was performed using Stata BE software (version 17.0; StataCorp, College Station, TX).
Results
Baseline characteristics
Survey responses from all 577 patients enrolled in the study were included in the statistical analyses. Because of the nature of the survey, patients had the opportunity to decline answers on the survey. Missing data were categorized as missing in the final assessment of responses; however, the maximum number of missing variables per survey on any single survey was 63 of 573 (11%); thus, all completed surveys were at least 89% completed. Declined response rates to each question in this manuscript are listed in Tables 1 and 2. The declined response rates that were significantly different between groups were household income (29 declined responses for a 93.8% response rate in referent group vs 20 declined responses for an 84.0% response rate in the pandemic group; P<.01), feeling safe in their neighborhood (22 declined responses for a 95.1% response rate in the referent group vs 0 declined responses for a 100% response rate in the pandemic group; P=.03), physical abuse during pregnancy (23 declined responses for a 94.9% response rate in the referent group vs 0 declined responses for a 100% response rate in the pandemic group; P<.01), and their utilities being shut off (57 declined responses for an 87.4% response rate in the referent group vs 0 declined responses for a 100% response rate in the pandemic group; P<.01). Of the 577 mothers enrolled, 125 (21.7%) had deliveries on or after March 30, 2020, and 452 (78.3%) had deliveries before March 30, 2020. There were significant differences in baseline maternal characteristics between the 2 periods, including maternal age at delivery, race and ethnicity, and household income (table 1). The mean age at delivery was higher in the pandemic group than in the referent group (28.7±6.1 years vs 26.2±5.9 years; P<.01). The pandemic group was composed of a higher proportion of Hispanic mothers than the prepandemic group (16.8% vs 3.6%; P<.01), whereas the prepandemic group was composed of a higher proportion of non-Hispanic Black mothers than the pandemic group (53.2% vs 36.8%; P<.01). Although the incomes were different between groups, in both periods, most study participants reported an annual household income of <$40,000.
Table 1.
Comparison of baseline maternal characteristics between mothers with pregnancies delivering before and during the COVID-19 pandemic
| Maternal characteristics | Prepandemic, births before March 30, 2020 (n=452) | Pandemic, births on or after March 30, 2020 (n=125) | P value |
|---|---|---|---|
| Age at delivery (y) | 26.2 (±5.9) | 28.7 (±6.1) | <.01a |
| Race and ethnicitya | <.01a | ||
| Non-Hispanic White | 176 (39.0) | 51 (40.8) | |
| Non-Hispanic Black | 240 (53.2) | 46 (36.8) | |
| Hispanic or Latino | 16 (3.6) | 21 (16.8) | |
| Asian | 14 (3.1) | 5 (4.0) | |
| Multiracial or other | 5 (1.1) | 2 (1.6) | |
| Pregnancy weight gain (lb) | 26.6 (±23.6) | 28.1 (±18.2) | .50 |
| BMI (kg/m2; before pregnancy) | .80 | ||
| <18.5 | 21 (4.7) | 4 (3.2) | |
| 18.5–24.9 | 150 (33.5) | 42 (33.6) | |
| 25.0–29.9 | 112 (25.0) | 31 (24.8) | |
| ≥30.0 | 165 (36.8) | 48 (38.4) | |
| Gravida | 2 (1–4) | 3 (2–4) | .09 |
| Para | 2 (1–3) | 2 (1–3) | .10 |
| Interpregnancy interval (mo) | 43.8 (±38.7) | 45.5 (±34.9) | .70 |
| Mother's highest level of educationb | .80 | ||
| 9–12th grade, no diploma, or less | 124 (27.6) | 31 (24.8) | |
| High school graduate or GED complete | 125 (27.8) | 36 (28.8) | |
| Some college credit but no degree or higher (associate, bachelor, doctorate) | 200 (44.5) | 58 (46.4) | |
| Median household incomec | <.01a | ||
| <$40,000 | 341 (80.6) | 67 (63.8) | |
| $40,000–$80,000 | 42 (9.9) | 16 (15.2) | |
| >$80,000 | 40 (9.5) | 22 (21.0) | |
| Hours worked per week during pregnancy | 19.3 (±18.4) | 24.7 (±18.4) | <.01a |
| Any alcohol use during pregnancyd | 57 (13.0) | 15 (12.1) | .80 |
| Any drug use during pregnancye | 64 (14.2) | 16 (12.8) | .70 |
| Any tobacco use during pregnancyf | 115 (26.0) | 34 (27.4) | .80 |
The pandemic group included deliveries on or after March 30, 2020. Data are presented as mean (±standard deviation), number (percentage), or median (interquartile range), unless otherwise indicated.
BMI, body mass index; GED, General Educational Development.
Of note, 1 patient in the referent group and 0 patient in the pandemic group declined to answer regarding race
Of note, 3 patients in the referent group and 0 patient in the pandemic group declined to answer regarding education
Of note, 29 patients in the referent group and 20 patient in the pandemic group declined to answer regarding household income
Of note, 14 patients in the referent group and 1 patient in the pandemic group declined to answer regarding alcohol use
Of note, 1 patients in the referent group and 0 patient in the pandemic group declined to answer regarding any drug use
Of note, 10 patients in the referent group and 1 patient in the pandemic group declined to answer regarding tobacco use.
Hefelfinger. Influence of COVID-19 on social determinants. Am J Obstet Gynecol Glob Rep 2023.
Table 2.
Social determinants of health between mothers with pregnancies delivering before and during the COVID-19 pandemic
| Variable | Pregnancies delivering before March 30, 2020 (n=452) | Pregnancies delivering on or after March 30, 2020 (n=125) | Relative risk (95% CI) |
|---|---|---|---|
| Large household (>5 persons)a | 106 (24.2) | 31 (25.2) | 1.04 (0.74–1.47) |
| Lived in shelter during pregnancyb | 13 (3.1) | 3 (2.5) | 0.80 (0.23–2.78) |
| Utilities cut off for monetary reasonsc | 15 (3.8) | 4 (3.2) | 0.86 (0.29–2.54) |
| No access or limited transportationd | 159 (36.7) | 19 (15.2) | 0.41 (0.27–0.64)e |
| Feels unsafe in neighborhoodf | 37 (8.6) | 15 (12.0) | 1.40 (0.80–2.47) |
| Limited social or emotional supportg | 47 (10.9) | 22 (17.7) | 1.62 (1.02–2.59)e |
| Less than moderate joy or happiness in the past yearh | 37 (8.6) | 8 (6.5) | 0.75 (0.36–1.58) |
| Limited prenatal care (<5 visits) | 109 (24.1) | 21 (16.8) | 0.70 (0.46–1.06) |
| Delayed or late first prenatal care visit (after 14 wk) | 160 (36.9) | 27 (22.9) | 0.62 (0.44–0.88)e |
| Medicaid utilization | 293 (64.8) | 58 (46.4) | 0.72 (0.59–0.87)e |
| Utilization of food stamps | 245 (54.2) | 36 (28.8) | 0.53 (0.40–0.71)e |
| WIC utilization | 292 (64.6) | 59 (47.2) | 0.73 (0.60–0.89)e |
| Experienced physical abuse during pregnancyi | 9 (2.1) | 2 (1.6) | 0.78 (0.17–3.54) |
| Experienced verbal abuse before or during pregnancyj | 79 (18.8) | 25 (20.5) | 1.09 (0.73–1.63) |
| Discrimination based on racek | 48 (11.3) | 22 (18.0) | 1.59 (1.00–2.53)e |
Data are presented as number (percentage), unless otherwise indicated.
CI, confidence interval; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children
Of note, 14 patients in the referent group and 2 patients in the pandemic group declined to answer regarding household size
Of note, 33 patients in the referent group and 5 patients in the pandemic group declined to answer regarding living in a shelter
Of note, 57 patients in the referent group and 0 patient in the pandemic group declined to answer regarding their utilities being cut off
Of note, 19 patients in the referent group and 0 patient in the pandemic group declined to answer regarding no access to transportation
XXX
Of note, 22 patients in the referent group and 0 patient in the pandemic group declined to answer regarding feeling unsafe in their neighborhood
Of note, 21 patients in the referent group and 1 patients in the pandemic group declined to answer regarding limited social or emotional support
Of note, 22 patients in the referent group and 2 patients in the pandemic group declined to answer regarding less than moderate joy or happiness in the past year
Of note, 23 patients in the referent group and 0 patient in the pandemic group declined to answer regarding physical abuse during pregnancy
Of note, 32 patients in the referent group and 3 patients in the pandemic group declined to answer regarding verbal abuse before or during pregnancy
Of note, 27 patients in the referent group and 3 patients in the pandemic group declined to answer regarding discrimination based on race.
Hefelfinger. Influence of COVID-19 on social determinants. Am J Obstet Gynecol Glob Rep 2023.
Social determinants of health
Among the SDoH examined, there were several that demonstrated no significant difference between the pandemic and prepandemic groups. Similarities existed among indicators of quality of living conditions, including questions about large household size, living in a shelter during pregnancy, having utilities shut off, and feeling unsafe in the neighborhood. In questions about social and community context, there were similar responses to questions that asked about less than moderate joy or happiness during pregnancy and intimate partner violence during pregnancy. For healthcare access and quality, both groups had similar responses for limited prenatal care (Table 2).
Of note, 2 SDoH showed a significant increase in frequency in the pandemic group compared with the prepandemic group, with the pandemic group being more likely to report discrimination based on race (18.0% vs 11.3%; P=.049) (Table 2) and more likely to report limited social and emotional support (17.7% vs 10.9%; P=.047) (Table 2). Moreover, there were significant decreases in the utilization of federally funded programs, such as Medicaid, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and food stamps in the pandemic group compared with the prepandemic group (Table 3).
Table 3.
Comparison of pregnancy and newborn characteristics between mothers with pregnancies delivering before and during the COVID-19 pandemic
| Characteristic | Deliveries before March 30, 2020 | Deliveries on or after March 30, 2020 | P value |
|---|---|---|---|
| Birthweight (g) | 2972.6 (±1630.7) | 2895.6 (±679.0) | .6 |
| Gestational age at delivery (wk) | 37.2 (±3.7) | 37.2 (±3.0) | 1.0 |
| Gestational age at the first prenatal ultrasound (wk) | 15.3 (±7.8) | 12.9 (±7.4) | <.01 |
| Total number of prenatal care visits | 10 (6–12) | 12 (8–15) | <.01 |
| 1-min Apgar score of <7 | 62 (13.7) | 17 (13.6) | 1.0 |
| 5-min Apgar score of <7 | 20 (4.4) | 7 (5.6) | .6 |
| Abnormal conditions of the newborn | 123 (27.6) | 25 (20.0) | .09 |
| Assisted ventilation immediately after delivery | |||
| NICU admission | |||
| Newborn given surfactant replacement therapy | |||
| Antibiotics received by newborn for suspected sepsis | |||
| Seizure or serious neurologic dysfunction | |||
| Significant birth injury | |||
| Other | |||
| Congenital anomalies of the newborn | 12 (2.7) | 2 (1.6) | .5 |
Data are presented as mean (±standard deviation), median (interquartile), or number (percentage), unless otherwise indicated.
NICU, neonatal intensive care unit.
Hefelfinger. Influence of COVID-19 on social determinants. Am J Obstet Gynecol Glob Rep 2023.
Pregnancy and neonatal characteristics
Newborn characteristics were similar between the 2 periods and showed no significant difference in adverse outcomes (Table 3). However, various pregnancy characteristics showed several differences, including gestational age at the first sonogram and total number of prenatal care visits. Patients who delivered before the pandemic were more likely to have a later onset of prenatal care, with the gestational age at the first prenatal ultrasound for the prepandemic and pandemic groups being 15.3±7.8 and 12.9±7.4 weeks, respectively (P<.01). In addition, delayed or late prenatal care after 14 weeks of gestation was significantly higher in the prepandemic group (RR, 0.62; 95% CI, 0.44–0.88), and the prepandemic group reported fewer total number of prenatal care visits (P<.01).
Comment
Principal findings
In our cohort of prenatal patients, we identified a variety of SDoH affected by the pandemic. Interestingly, the pandemic was associated with fewer patients experiencing delayed prenatal care, improved access to transportation, and less use of federally funded programs. However, we also found that the pandemic cohort experienced more difficulties with limited social and emotional support and increased discrimination based on their race.
Results in the context of what is known
Although much research has focused on how COVID-19 as an illness affects pregnant patients, we sought to evaluate how the societal changes of a pandemic affect the SDoH for pregnant patients, as we postulated that the pandemic may have caused increased levels of personal and financial stress. It is unclear if the pandemic may have had some positive effects as well, as the pandemic forced an increased flexibility of appointments and increased governmental financial services.7,8 In our population, patients were more likely to have increased access to transportation, and this may have been the cause of the increased number of attended prenatal visits in the pandemic group and the earlier gestational age at the first prenatal visit in the pandemic group.
Clinical implications
Although we did note more frequent and earlier prenatal care in the pandemic group, and patients noting increased transportation access, this does not imply that all or even most changes to SDoH during the pandemic have been positive. In addition, our study population felt that they experienced more racism and less social support. Being able to attend prenatal care visits and having access to care is 1 piece in the large puzzle of addressing SDoH to create equity in medical care; however, if those benefits are offset by less support, the overall patient effect may be negative. Moreover, the finding of increased racism is a significant and concerning finding, which reflects survey data from Pew Research that indicated both Asian and Black Americans noted significantly increased racism during the pandemic.9 Our study was not equipped to assess the mental health implications of this; however, the pandemic's effect on mental health is well documented, and further research is needed to evaluate the interplay among the pandemic, SDoH, and mental health.10
Another potential question of interest that is somewhat left unanswered is how the declined response rate differences between groups reflect differences between groups. Specifically, there were 57 declined responses regarding shutting off utilities in the referent group and 0 declined responses in the pandemic group. Furthermore, it is notable that, during the pandemic, there was a period of state-imposed moratoriums on shutting off utilities, which may have affected these outcomes. Understanding the SDoH in the context of these missing data and the moratorium is a challenge.
Research implications
Somewhat surprisingly, patients in the pandemic group worked more than patients in the prepandemic group. This may have translated to the difference in household incomes. This change in hours worked may reflect also the type of work being done, as there was a shift with an increase in remote work and a large decrease in work in the service industry11 nationally, which may be an explanation for the trend we see. The other possibility is that we evaluated different populations during the prepandemic and pandemic times, given that there are differences in Medicaid and WIC utilization between groups. It is unclear whether this difference is a result of a changing population or the population being studied having more work (as shown in Tables 1 and 2) and, thus, income and access to healthcare. Although given that the survey was given consistently to a similar population at the same hospital, serving primarily an inner-city population, we do not suspect that the differences can be entirely ascribed to a changing population. In a separate study of pandemic-related changes in non-Hispanic Black patients only, we also saw similar changes, with increased job opportunities, earlier prenatal care, and an increase in feelings of racism, thus seeing whether these changes persist beyond the pandemic will be an area of interest.12
Strengths and limitations
A key strength of this study is the prospective nature of the data collection during the larger study and the consistency of the survey throughout the study. Another benefit of the survey is the timing, which occurred right at the pregnancy conclusion, which may limit recall bias because of the shorter lag time between events and the survey. Another strength is that this study adds to the limited existing research examining the effect of the COVID-19 pandemic on SDoH and evaluates SDoH in a standardized fashion. A limitation of this study is that, as the survey was administered directly to patients through study personnel, the social-desirability bias may have influenced responses, which may underestimate the influence of the pandemic on certain SDoH. Another limitation is missing responses or declined responses. For example, if patients answered the missing or declined responses, their responses may have differed from those who responded, affecting the results. Lastly, this study was conducted in an urban population and may not be generalizable to other geographic areas.
Conclusion
The COVID-19 pandemic led to significant changes in the SDoH for pregnant patients. Although patients had increased access to transportation and increased prenatal care, their overall level of support was lower. Therefore, further work is needed to improve the level of assistance for these patients.
Acknowledgments
We would like to thank Elena Bruno Andino for her contribution to the manuscript and table formatting.
Footnotes
The authors report no conflict of interest.
The University of Cincinnati Office of Research provided funding for researchers to administer surveys to patients.
This study was presented as a poster (abstract number 584) at the Society for Maternal-Fetal Medicine 42nd Annual Pregnancy Meeting, Orlando, FL, January 31, 2022, to February 5, 2022.
All patients are consented by study staff during study enrollment. Signed consents are kept on record.
Cite this article as: Hefelfinger LM, DeFranco EA, Mendez C, et al. Influence of the COVID-19 pandemic on social determinants of health among an inner-city obstetrical population. Am J Obstet Gynecol Glob Rep 2023;XX:x.ex–x.ex.
Supplementary material associated with this article can be found in the online version at doi:10.1016/j.xagr.2023.100225.
Appendix. Supplementary materials
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