R01NR020335

Building a Causal Pathway Framework to Identify Interventions to Eliminate Racial/Ethnic Disparities in Severe Maternal Morbidity - Abstract

The US is in the midst of a maternal health crisis. The US has worse maternal mortality (MM) than any other high-income country and is the only one for which the rate is increasing. Severe maternal morbidity (SMM), which encompasses conditions that put pregnant women most at risk of dying, doubled in the last two decades. Women of color, especially Black and Native American women, are at 2-3-fold or greater increased risk of these outcomes.

This proposal focuses on SMM as a sentinel outcome leading to MM, yet 100 times more common. Most prior research on SMM has focused on proximal clinical factors (primarily related to co-morbidities and obstetric management); these factors alone are insufficient for explaining SMM or its racial/ethnic disparities.

The objectives of this proposal are:
1) Develop a causal pathway framework to understand how social determinants and more proximal health-related factors together contribute to SMM risk and disparities, and
2) Use this framework to identify actionable strategies to reverse current trends and eliminate inequities.

We will create a unique dataset that harmonizes 4 years of data from 6 states on 4.4 million births and 66,000 women with SMM. These states collectively include 1 in 4 US births and sufficiently diverse social environments to disentangle complex multi-level drivers of maternal health inequity.

Our focus is on social determinants from 4 specific domains: socioeconomic disadvantage, structural inequality, community resources, and healthcare access, characterized at the county, neighborhood (census tract or zip code), and individual level. Health-related intermediaries include birth hospital quality of care, mode of birth, and maternal morbidities (e.g., hypertension, anemia). These domains and intermediaries were selected for their relevance to racial/ethnic disparities in maternal health.

In addition, we will evaluate impacts of 3 quality improvement (QI) collaboratives on SMM disparities, which were designed to improve specific aspects of hospital quality of care and implemented by state-wide perinatal quality collaboratives (PQCs) in 3 of the 6 states included in this proposal.

Our specific aims are:
1) Assess the relative and joint contributions of multi-level social determinants to SMM and SMM disparities;
2) Identify potential health-related mechanisms by which multi-level social determinants affect SMM and SMM disparities by conducting causal pathway analyses; and
3) Evaluate the impact of 3 QI collaboratives designed to reduce SMM on racial/ethnic disparities in SMM (3A), and apply the causal framework developed in Aims 1 and 2 to these state-specific contexts, to identify state-specific strategies for addressing SMM disparities (3B).

We currently have very limited understanding of how social determinants contribute to SMM or its disparities. The proposed research will fill this important knowledge gap, which is an essential part of realizing sustainable improvement of maternal health and elimination of racial/ethnic disparities.

The Leland Stanford Junior University

NURSES UNDERSTAND THAT IMPROVING HEALTH AND WELL-BEING MEANS ADDRESSING PEOPLE'S NEEDS IN MULTIPLE SETTINGS, CONTEXTS, AND OVER THE WHOLE LIFE COURSE. SCIENCE SUPPORTED BY THE NATIONAL INSTITUTE OF NURSING RESEARCH (NINR) USES THIS HOLISTIC PERSPECTIVE TO IMPROVE INDIVIDUAL AND POPULATION HEALTH AND ADVANCE HEALTH EQUITY. NINR-SUPPORTED RESEARCH PROMOTES HEALTH AND WELL-BEING BY ADDRESSING NEEDS AT MULTIPLE LEVELS INDIVIDUAL, FAMILY, COMMUNITY, AND SOCIETAL LEVELS AND DEVELOPING TREATMENT AND PREVENTION STRATEGIES THAT ARE RESPONSIVE TO THE REALITY OF PEOPLE'S LIVES. NURSES KNOW PEOPLE, AND PEOPLE TRUST NURSES. PATIENT AND FAMILIES INTERACT WITH NURSES MORE THAN ANY OTHER CLINICIANS. NURSING SCIENCE USES THIS SPECIAL RELATIONSHIP TO BETTER UNDERSTAND PATIENTS, FAMILIES, AND COMMUNITIES AND THE MANY FACTORS THAT INFLUENCE THEIR HEALTH. NURSING SCIENCE SUPPORTED BY NINR USES THIS KNOWLEDGE TO DEVELOP STRATEGIES FOR IMPROVING HEALTH AND WELLNESS ACROSS POPULATIONS, HEALTH CARE SETTINGS, AND THE LIFESPAN, WITH AN EMPHASIS ON ACHIEVING HEALTH EQUITY. NINR-SUPPORTED SCIENTISTS HAVE DEVELOPED INTERVENTIONS FOR: SUPPORTING PARENTS OF PREMATURE INFANTS, PROMOTING HIV PREVENTION IN UNDERSERVED POPULATIONS, IMPROVING TRANSITIONAL CARE LEADING TO BETTER OUTCOMES AND COST-SAVINGS, AND HELPING INNER-CITY CHILDREN MANAGE ASTHMA. NURSING SCIENCE TRANSCENDS THE BOUNDARIES OF DISEASE AND RESEARCH DISCIPLINES TO BETTER UNDERSTAND THE EXPERIENCES OF INDIVIDUALS AND FAMILIES LIVING WITH ILLNESS AND TO DEVELOP PERSONALIZED APPROACHES THAT MAXIMIZE HEALTH AND WELL-BEING FOR INDIVIDUALS AT ALL STAGES OF LIFE, ACROSS DIVERSE POPULATIONS AND SETTINGS. NINR-SUPPORTED SCIENCE USES NURSING SCIENCE'S UNIQUE, PATIENT AND COMMUNITY-FOCUSED PERSPECTIVE AND WIDE REACH ACROSS CLINICAL AND COMMUNITY SETTINGS TO ADVANCE OUR UNDERSTANDING OF THE SOCIAL DETERMINANTS OF HEALTH: THOSE FACTORS THAT ARE AT THE ROOT OF THE INEQUITIES THAT WE SEE, SUCH AS FOOD INSECURITY AND ACCESS TO HEALTHCARE. NINR RESEARCH EFFORTS IN WELLNESS INVESTIGATE THE KEY BIOLOGICAL, BEHAVIORAL, AND SOCIAL FACTORS THAT PROMOTE LONG-TERM HEALTH AND HEALTHY BEHAVIORS AND PREVENT THE DEVELOPMENT OF ILLNESS ACROSS HEALTH CONDITIONS, SETTINGS, AND THE LIFESPAN. RESEARCH IN WELLNESS IS ALSO FOCUSED ON DEVELOPING AND TESTING CULTURALLY APPROPRIATE INTERVENTIONS TO PROMOTE HEALTH AND PREVENT ILLNESS IN MINORITY AND UNDERSERVED GROUPS. NINR ALSO SUPPORTS SCIENCE TO ASSIST INDIVIDUALS, FAMILIES, AND HEALTH CARE PROFESSIONALS IN MANAGING ADVANCED, SERIOUS ILLNESS, AND PLANNING FOR END-OF-LIFE DECISIONS. IN ADDITION, NINR PROMOTES TECHNOLOGICAL ADVANCEMENTS THAT ADDRESS A RANGE OF HEALTH CARE CHALLENGES AND FACILITATE THE DELIVERY OF REAL-TIME PERSONALIZED INFORMATION TO INDIVIDUALS AND FAMILIES, HEALTH CARE PROVIDERS, AND COMMUNITIES. FINALLY, NINR HAS A LONGSTANDING AND CONTINUING COMMITMENT TO DEVELOPING THE NEXT GENERATION OF NURSE SCIENTISTS: THOSE INDIVIDUALS AND TEAM MEMBERS WHO WILL CARRY THE FIELD OF NURSING SCIENCE INTO THE FUTURE. IN ORDER TO PREPARE AN INNOVATIVE, DIVERSE, AND TALENTED NEXT GENERATION OF NURSE SCIENTISTS, NINR SUPPORTS A VARIETY OF TRAINING OPPORTUNITIES FOR SCIENTISTS AND TRAINEES AT ALL CAREER LEVELS, PARTICULARLY THOSE AT AN EARLY CAREER STAGE WHO ARE SO CRITICAL TO SUSTAINING THE FUTURE OF INNOVATIVE RESEARCH AND HIGH QUALITY HEALTH CARE.

93.361 - Nursing Research

National Institute of Nursing Research (NINR) [HHS - NIH]

Stanford, California 94305 United States

Single Zip Code

NIH Research Project Grant (Parent R01 Clinical Trial Not Allowed) (PA-20-185)

Amendment Since initial award the total obligations have increased 391% from $745,932 to $3,660,423.