Table 4.

Summary of Social Determinants and Maternal Outcome Associations by Volume of Studies: Material and Physical Circumstances

↑ = 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
Area-Level Characteristics
Low-income neighborhoods by zip code (5/8 positive findings)	Pregnancy-related mortality ↑ [31]; ↑ For white women[28] — For black women[28] In-hospital mortality — Cases vs. controls[69]	Individual outcomes — For ectopic pregnancy outcomes[55] — Peri- and post-partum stroke[73] Overall composite SMM ↑ Unadjusted, — adjusted: for median household incomes <$81,874 compared to >$123,856[56]	↑ ED visit within 90 days of delivery[64] ↑ Postpartum readmission[62]
High-income neighborhoods by zip code (3/3 positive findings)	Reference, unless otherwise stated	Overall composite SMM ↓ Compared to lowest quartile of income[26,44] Individual outcomes ↓ Hysterectomy, highest quartile compared to lowest quartile[84]
% unemployment (1/1 positive finding)			↑ By zip code: ectopic-pregnancy hospitalization longer than 2 days[75]
% of female-headed households (1/1 positive finding)		By zip code: ↑ >12% vs. <6.1%, Unadjusted[56]
% of women without high school diploma (2/3 positive findings)	Maternal mortality ratio By state MMR ranking: ↑ [83], — [38]	By zip code: ↑ >6.2 vs. <1.8%, Unadjusted[56]
% women uninsured (1/2 positive findings)	Maternal mortality ratio By state MMR ranking: —% Deliveries paid by governmental insurance [38] —% Women with health care coverage [38]	By zip code: ↑ >7.4% vs <2.2% Unadjusted[56]
% people living below poverty line (2/3 positive findings)	Maternal mortality ratio By state MMR ranking: — [38]	By zip code: ↑ Severe sepsis[67] ↑ >9.2% vs. <2.9% Unadjusted[56]
% race (3/4 positive findings)	Maternal mortality ratio By state MMR ranking: ↑ % Deliveries to African American women [38,83] —% Deliveries to Hispanic, Native American, Asian women [38]		↑ Patients from more African American zip codes experienced longer hospitalizations related to ectopic-pregnancy than others[75]
% unmarried mothers (1/1 positive finding)	Maternal mortality ratio By state MMR ranking: ↑ [38]
% rural population (0/1 positive finding)	Maternal mortality ratio By state MMR ranking: — [38]
Hospital characteristics
Minority-serving or % of minority deliveries compared to white-serving or % white deliveries (5/5 positive findings)	In-hospital mortality ↑ [27]	Overall composite SMM ↑ [27,56,59,87]
Hospital teaching status, ownership, nursery level and volume of deliveries; risk-standardized severe maternal morbidity rates (1/1 positive finding)		Overall composite SMM ↓ Teaching status, Level 3/4 nursery, private ownership, and very high-volume status; but did not fully account for excess risk among black women[88]
Public vs. Private (reference) (1/1 positive finding)	In-hospital mortality ↑ for Hispanic-serving hospitals[27]
Rural vs. Urban (reference) (2/4 positive findings)	In-hospital mortality — [86]	Individual outcomes — For ectopic pregnancy outcomes[55]	↑ Postpartum readmission for women delivering in a rural vs. urban hospital[62] ↑ For ectopic pregnancy hospitalizations >4 days[55]
% of Medicaid-insured or uninsured (1/1 positive finding)		↑ [56]