Table 3.

Summary of Social Determinants and Maternal Outcome Associations by Volume of Studies: Socioeconomic Position and Individual Factors

↑ = increased risk or positive association, ↓ = decreased risk or negative association, — = no association or not significant “Positive finding” indicates the number of studies showing significant associations in the same direction
Race and Ethnicity (58/67 positive findings for minority groups compared to non-Hispanic White)
Non-Hispanic White	Reference, except otherwise stated	Reference, except otherwise stated ↑ Anesthetic complications, compared to black women[65]
Non-Hispanic Black (53/60 positive findings)	Cause-specific deaths ↑ Ectopic pregnancy[21,42] ↑ Abortion[22] ↑ Cardiovascular causes[30] ↑ Preeclampsia, eclampsia or pregnancy-induced hypertension[36,39] ↑ Hemorrhage[39] ↑ Case-fatality rates for preeclampsia, eclampsia, placental abruption, placenta previa and postpartum hemorrhage[43] — Mortality after pregnancy-related intracerebral hemorrhage[23] In-hospital mortality ↑ [24–27,29,32,41] ↑ At white-serving but not black- or Hispanic-serving hospitals[27] — [69] Pregnancy-related mortality ↑ [28,31,33–35,37–40] Failure-to-rescue ↑ [44] Preventability of maternal death —[45]	Overall composite SMM ↑ [26,27,29,41,44,49–51,53,54,56,58] ↑ Particularly among cesarean deliveries[60,61] ↑ Among women with cardiomyopathy in a non-teaching hospital[52] ↓ Among those with inpatient ectopic pregnancies[55] — Mothers with HIV, black vs non-black[124] — Among those with pre-viable premature rupture of membranes, black vs. non-black[125] Individual outcomes ↑ Severe sepsis[67,71] ↑ Intracerebral hemorrhage[23] ↑ Postpartum hemorrhage[126–128] ↑ Severe preeclampsia or eclampsia[49,72,129–131] — Severe preeclampsia[132] — Eclampsia[76] ↑ Peripartum transfusion[49,74,133,134] ↑ Stroke [73] ↑ Intracranial venous thrombosis, among Medicaid patients[135] ↑ Acute renal failure[49,133] ↑ Heart failure, mechanical ventilation, acute respiratory distress syndrome[49] ↑ Hysterectomy in low-risk patients[84] ↓ Uterine rupture[66]	↑ Postpartum readmission[61,62] ↑ ED visit within 90 days of delivery[64] ↑ Pregnancy-associated hospitalization[63] ↑ Ectopic pregnancy hospitalization >4 days[55]
Hispanic (24/30 positive findings)	Pregnancy-related mortality ↑ [28,46] — [33,39,47] ↓ [34,35] In-hospital mortality ↑ [26,29] — [41] Among women with preeclampsia or eclampsia Cause-specific deaths ↑ Intracerebral hemorrhage[23,39,46] ↑ Pregnancy-induced hypertension[39,46] ↑ Hemorrhage[46] ↑ Mortality after pregnancy-related intracerebral hemorrhage[23] — Hemorrhage[39]	Overall composite SMM ↑ [26,29,50,51,53,57–60] ↑ Among women with cardiomyopathy in a non-teaching hospital[52] — Among those with inpatient ectopic pregnancies[55] Individual outcomes ↑ Blood transfusion[49,133] ↑ Hysterectomy[49]; in low-risk patients[84] ↑ Acute renal failure [133] ↑ Severe sepsis[67,71] ↑ Postpartum hemorrhage[126–128] ↑ Eclampsia[72] — Intracranial venous thrombosis, among Medicaid patients [135]	↑ Ectopic pregnancy hospitalization >4 days[55]
Asian-Pacific Islander (14/16 positive findings)	In-hospital mortality ↑ [48] — [26] Cause-specific deaths — Mortality after pregnancy-related intracerebral hemorrhage[23]	Overall composite SMM ↑ [26,48,50,51,53,56] ↑ Among women with cardiomyopathy in a non-teaching hospital[52] — Among those with inpatient ectopic pregnancies[55] Individual outcomes ↑ Severe sepsis[67,71] ↑ Postpartum hemorrhage[126,128] ↑ Peripartum transfusion[49,74] ↑ Eclampsia[72] ↑ Hysterectomy[49]	— Ectopic pregnancy hospitalization >4 days [55]
Native American and American Indian (4/4 positive findings)		Overall composite SMM ↑ [26,50] Individual outcomes ↑ Transfusion and hysterectomy[49] ↑ Eclampsia[136]
Insurance (21/30 positive findings for public or no insurance coverage compared to private insurance)
Private insurance (2/3 positive findings)	Reference, unless otherwise stated	Reference, unless otherwise stated Overall composite SMM ↓ Compared to Medicaid[26] — Among mothers with pre-viable PROM, as compared to non-private insurance or no insurance [125] Individual outcomes ↓ Hysterectomy, compared to Medicare[84]
No private insurance (no insurance + public insurance combined variable)		Individual outcomes ↑ Severe sepsis[71]
No insurance or self-pay (9/12 positive findings)	Cause-specific deaths ↑ Severe sepsis[67] ↑ Acute respiratory distress syndrome[68] In-hospital mortality ↑ [25,44,45,68] — [69]	Overall composite SMM ↑ [44,53,60] — With blood transfusion, ↑ without blood transfusion [56] Individual Outcomes ↑ Severe sepsis[67] — Anesthesia-complications[65] — Hysterectomy, compared to Medicare [84]	↑ Pregnancy-associated hospitalizations[63]
Public insurance (14/24 positive findings)	Cause-specific deaths ↑ Cardiovascular death[30] In-hospital mortality ↑ [44,45] — [29,69,70] — by State Medicaid coverage of medically necessary abortion[18]	Overall composite SMM ↑ [44,50,53,60]; Compared to non-Medicaid[58] ↑ Among women with cardiomyopathy [52] — [61] — [56] ↓ For Medicaid managed care vs. private managed care[70] Individual outcomes ↑ Eclampsia[72] — Ectopic-pregnancy related[55,75] — Peri- and post-partum stroke[73] — Anesthesia-complications[65] — Peripartum transfusion[74] — Hysterectomy, compared to Medicare[84]	↑ Pregnancy-associated hospitalizations[63] ↑ Postpartum readmission[62] ↑ ED visit within 90 days of delivery[64] ↑ Ectopic pregnancy hospitalization >4 days[55] >2 days[75]
Type of insurance		Overall composite SMM — For Medicaid managed care vs. fee-for-service[70] Individual outcomes ↑ Preeclampsia, for Medicaid managed care vs. fee-for-service[70]
Maternal Education
High school education or more (1/2 positive finding)	Reference unless otherwise stated	Reference unless otherwise stated Overall composite SMM ↓ Some post-graduate as compared to high school[53]; college graduate or higher as compared to high school graduate only for cesarean deliveries[60] — Some college as compared to high school[53]; college graduate or higher as compared to high school graduate only for vaginal deliveries[60]
Less than high school education (8/12 positive findings)	Pregnancy-related mortality ↑ [28,33] ↑ Impact higher on black women than white women[28] — [47] ↑ But dropped out of regression model after adjustment[31] Maternal mortality (within 42 days) ↑ Rates, unadjusted [33] In-hospital mortality — [25,29]	Overall composite SMM ↑ Compared to high school graduate only, both vaginal and cesarean deliveries[60] ↑ <8 years of education compared to >12 years of education, for vaginal deliveries[61] — <8 years of education compared to >12 years of education, for cesarean deliveries [61] — [29,58] Individual Outcomes ↑ Sepsis[71] ↑ Eclampsia[72,76]
Marital Status
Married	Reference, unless otherwise stated	Reference, unless otherwise stated
Unmarried (5/10 positive findings)	Pregnancy-related mortality ↑ [33,39] ↑ among white women but not black women[28] — [47,69] In-hospital mortality — [29]	Overall composite SMM — [29,58] — ICU admission[54] ↑ [60] Individual Outcomes ↑ Missing compared to no missing paternal information; risk of eclampsia[77]
Residence
Region of residence (5/6 positive findings)	Maternal mortality (within 42 days) ↑ in South vs other parts of US[33] — In boroughs in NYC vs. Bronx[47] Pregnancy-related mortality (within 1 year) ↑ in Mississippi Delta vs. non-Delta regions[78] ↑ in Chicago city vs. suburbs and remainder of Illinois[39]	Overall composite SMM ↑ in Northeastern, Northern, Southeastern, Southern vs Western part of Wisconsin[50] ↑ in all parts of Maryland vs Baltimore metro[56]
Rurality (urban vs. non-urban) (3/5 positive findings)		Overall composite SMM ↑ For non-urban versus urban residence[58] — [61] — Among low-risk women planning midwife-led community birth[85] Individual outcomes ↑ Anesthesia-complications[65]	↑ Patients from more urban zip codes experienced longer hospitalizations related to ectopic-pregnancy than others.[75]
Nativity or country of origin
US-Born	Reference
Foreign-Born (3/6 positive findings)	In-hospital mortality — [25] Pregnancy-related mortality — [47] ↑ Foreign-Born Hispanic vs. US-born Hispanic [46]	Overall composite SMM ↑ Foreign-Born Hispanic vs. US-born Hispanic [59,79] —[60]
Maternal employment status
Employed	Reference	Reference
Unemployed (1/2 positive findings)	In-hospital mortality — [25]	Overall composite SMM — [57]; For vaginal deliveries [60] ↑ For cesarean deliveries[60]
Other
Physical violence or abuse during pregnancy (3/3 positive findings)		Individual outcomes ↑ Uterine rupture, transfusion, hemorrhage, infection[80]	↑ Pregnancy-associated hospitalization[81,82] ↑ Postpartum readmission[80]
Individual household income(1/1 positive finding)		Individual outcomes — Comparing first (<$32,669) and third tertile (>$44,485) of annual household income vs second tertile ($32,669–44,485) for eclampsia[76]