Structural Racism and Severe Maternal Morbidity in New York State

Objective: We examined the association between county-level structural racism indicators and the odds of severe maternal morbidity (SMM) in New York State. Design: We merged individual-level hospitalization data from the New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS) with county-level data from the American Community Survey and the Vera Institute of Justice from 2011 to 2013 (n = 244 854). Structural racism in each county included in our sample was constructed as the racial inequity (ratio of black to white population) in female educational attainment, female employment, and incarceration. Results: Multilevel logistic regression analysis estimated the association between each of these structural racism indicators and SMM, accounting for individual- and hospital-level characteristics and clustering in facilities. In the models adjusted for individual- and hospital-level factors, county-level racial inequity in female educational attainment was associated with small but statistically significant higher odds of SMM (odds ratio [OR] = 1.17, 95% confidence interval [CI] = 1.47, 1.85). County-level structural racism indicators of female employment inequity and incarceration inequity were not statistically significant. Interaction terms examining potential effect measure modification by race with each structural racism indicator also indicated no statistical difference. Conclusions: Studies of maternal disparities should consider multiple dimensions of structural racism as a contributing cause to SMM and as an additional area for potential intervention.