Social determinants of health and coronavirus disease 2019 in pregnancy

Abstract

Background: The social and physical environments in which people live affect the emergence, prevalence, and severity of both infectious and noninfectious diseases. There are limited data on how such social determinants of health, including neighborhood socioeconomic conditions, affect the risk of severe acute respiratory syndrome coronavirus 2 infection and severity of coronavirus disease 2019 during pregnancy.

Objective: Our objective was to determine how social determinants of health are associated with severe acute respiratory syndrome coronavirus 2 infection and the severity of coronavirus disease 2019 illness in hospitalized pregnant patients in New York during the global coronavirus disease 2019 pandemic.

Study design: This cross-sectional study evaluated all pregnant patients who delivered and had polymerase chain reaction testing for severe acute respiratory syndrome coronavirus 2 between March 15, 2020, and June 15, 2020, at 7 hospitals within Northwell Health, the largest academic health system in New York. During the study period, universal severe acute respiratory syndrome coronavirus 2 testing protocols were implemented at all sites. Polymerase chain reaction testing was performed using nasopharyngeal swabs. Patients were excluded if the following variables were not available: polymerase chain reaction results, race, ethnicity, or zone improvement plan (ZIP) code of residence. Clinical data were obtained from the enterprise electronic health record system. For each patient, ZIP code was used as a proxy for neighborhood. Socioeconomic characteristics were determined by linking to ZIP code data from the United States Census Bureau's American Community Survey and the Internal Revenue Service's Statistics of Income Division. Specific variables of interest included mean persons per household, median household income, percent unemployment, and percent with less than high school education. Medical records were manually reviewed for all subjects with positive polymerase chain reaction test results to correctly identify symptomatic patients and then classify those subjects using the National Institutes of Health severity of illness categories. Classification was based on the highest severity of illness throughout gestation and not necessarily at the time of presentation for delivery.

Results: A total of 4873 patients were included in the study. The polymerase chain reaction test positivity rate was 11% (n=544). Among this group, 359 patients (66%) were asymptomatic or presymptomatic, 115 (21%) had mild or moderate coronavirus disease 2019, and 70 (13%) had severe or critical coronavirus disease 2019. On multiple logistic regression modeling, pregnant patients who had a positive test result for severe acute respiratory syndrome coronavirus 2 were more likely to be younger or of higher parity, belong to minoritized racial and ethnic groups, have public health insurance, have limited English proficiency, and reside in low-income neighborhoods with less educational attainment. On ordinal logit regression modeling, obesity, income and education were associated with coronavirus disease 2019 severity.

Conclusion: Social and physical determinants of health play a role in determining the risk of infection. The severity of coronavirus disease 2019 illness was not associated with race or ethnicity but was associated with maternal obesity and neighborhood level characteristics such as educational attainment and household income.

Keywords: COVID-19; SARS-CoV-2; ZIP code tabulation areas; health disparities; neighborhood characteristics; social determinants of health; socioeconomic conditions.

Figure 1

Flowchart of study patients COVID-19, coronavirus disease 2019; PCR, polymerase chain reaction; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2. Prasannan. Social determinants of health and coronavirus disease 2019. Am J Obstet Gynecol MFM 2021.

Figure 2

SARS-CoV-2 infection in pregnant patients by ZIP Code. ZIP, zone improvement plan. Prasannan. Social determinants of health and coronavirus disease 2019. Am J Obstet Gynecol MFM 2021.

Figure 3

Association of neighborhood characteristics with SARS-CoV-2 infection and COVID-19 severity. A, Association of neighborhood median annual household income with SARS-CoV-2 infection and COVID-19 severity. B, Association of neighborhood mean persons per household with SARS-CoV-2 infection and COVID-19 severity. C, Association of neighborhood unemployment rate with SARS-CoV-2 infection and COVID-19 severity. D, Association of neighborhood high school graduation rate with SARS-CoV-2 infection and COVID-19 severity. COVID-19, coronavirus disease 2019; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2. Prasannan. Social determinants of health and coronavirus disease 2019. Am J Obstet Gynecol MFM 2021.