A Socioecological Analysis of Risk and Protective Factors for High-Risk Pregnancies Among Black Women

Abstract

Black women are approximately three times more likely to die from pregnancy-related causes than White women in the United States. Gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP) are the leading causes of maternal morbidity and pregnancy-related deaths and disproportionately impact Black women. Individual-level risk factors for GDM and HDP have been well established, but they do not fully explain differential maternal health outcomes between Black and White women in the United States. This suggests the complex interplay of individuals and their environments contributes to maternal health inequities rather than individual-level attributes alone. The purpose of this dissertation was to generate a comprehensive understanding of multilevel factors influencing the onset, experiences, and outcomes of GDM and HDP among Black women drawing from intersectionality, the socioecological framework, and the society-to-cell resilience frameworks. This dissertation includes a systemic review of the literature including 19 original research studies to identify risk and protective factors for GDM and HDP beyond the individual level (Chapter 2). A qualitative descriptive study was conducted with Black women with a history of GDM or HDP (N=14) to describe their perceptions of positive versus harmful patient-clinician interaction, examine the role of racial concordance, and describe the short-term and potential long-term outcomes of these clinician interactions (Chapter 3). In addition, a secondary analysis of Black women with a history of pregnancy (N= 1,119) from the National Longitudinal Study of Adolescent to Adult Health using latent profile analysis was conducted to (1) identify subgroups of women with differing structural gendered racism experiences, and (2) determine the sociodemographic characteristics, clinical characteristics, and interpersonal discrimination experiences associated with the identified subgroups (Chapter 4). Interpersonal, community/environmental, and societal-level risk and protective factors contribute to the onset of GDM and HDP among Black women along with their short-term and long-term health outcomes. Interpersonal interactions with partners and providers have implications for maternal health outcomes as the perinatal period may be particularly sensitive to unsupportive or abusive relationships. Community/environmental risk and protective factors were underexamined for GDM, but neighborhood crime and low levels of greenspace were associated with increased risk for HDP. The relationship between various forms of structural racism and sexism (societal level) is not well understood for the outcomes of GDM and HDP but is associated with adverse maternal health outcomes broadly in the literature. The findings from this dissertation can (1) inform areas for future research to develop multilevel interventions to overcome systemic inequalities and enhance measurement of structural gendered racism; (2) inform maternity care; (3) identify areas for policy reform.