UC Berkeley

In the United States, severe maternal morbidity (SMM), which encompasses a broad spectrum of unexpected and life-threatening health complications that occur during the antepartum, intrapartum, or postpartum periods, has increased threefold between 1993-2014. SMM disproportionately affects Black, Hispanic, Indigenous, Asian, and Pacific Islander birthing people, an alarming and persistent inequity that remains an unaddressed public health crisis. Individual, clinical, and hospital-level factors have failed to account for these disparities, highlighting the need to examine upstream factors, such as structural racism, in relation to pregnancy-related health outcomes for birthing people. Neighborhood context is a profound determinant of infant health outcomes, but evidence of how neighborhood environments influence pregnancy-related mortality and morbidity is lacking. Even fewer studies have examined sociopolitical and geospatial manifestations of structural racism, such as racial residential segregation and gentrification, that create differential neighborhood social and material conditions, which produce stark racial/ethnic differences in SMM.

To address these important gaps in knowledge, the overarching objective of this dissertation is to investigate the impact of place-based sociopolitical mechanisms of structural racism on racial and ethnic inequities in pregnancy-related morbidity. This work leverages a state-wide population-based sample of over 11 million births in California between 1997-2018. The first Chapter assesses associations between historical redlining, a federally institutionalized program that exemplified housing discrimination, and present-day SMM outcomes. The second Chapter examines associations between contemporary gentrification and SMM, comparing three different exposure assessment methods to determine which measure of gentrification best captures features salient to pregnancy-related outcomes. The third Chapter investigates the joint impact of historical redlining and contemporary gentrification on SMM outcomes. Given the especially stark SMM disparities impacting Black and Indigenous birthing persons, these Chapters further investigate whether redlining and gentrification differentially impact racially marginalized groups. This work is the first to assess the interconnected influence of historical policies and contemporary neighborhood changes on SMM. This dissertation has important strengths and innovations. The use of a large population-based dataset with sufficient racial and ethnic, geographic, and socioeconomic heterogeneity allows for robust investigations of the root causes of SMM, a rare event that impacts 1% of the population. Moreover, investigating novel exposure measures, including redlining and gentrification, addresses a critical gap in knowledge. Given the urgency to address racial and ethnic inequities in pregnancy-related mortality and morbidity, findings from this dissertation can inform place-based interventions to promote equitable neighborhood development that benefits the most vulnerable populations, reducing SMM risk among birthing people in historically marginalized neighborhoods