Social determinants of health (SDOH) are the “conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes” (CDC, 2022). You may be wondering how these social determinants are related to pregnancy outcomes. Economic stability, an important determinant of health, involves financial resources such as income, cost of living, and socioeconomic status. Therefore, poverty, unemployment, food insecurity, and housing instability can influence pregnancy outcomes and complications. Research shows that higher socioeconomic status (SES) is associated with better pregnancy outcomes.

Financial hardship is highly prevalent among pregnant women. A weighted study representing more than 1 million women found that financial hardship was common from 2013–2018. Twenty-four percent of pregnant women reported unmet healthcare needs, 60 percent healthcare unaffordability, and 54 percent general financial stress (Taylor et al., 2021). Pregnancy outcomes associated with poverty include increased risk for preterm birth (babies that are born 37 weeks of pregnancy are completed), intrauterine growth restriction (when the baby in the uterus does not grow as expected), and neonatal and infant death. Additionally, experiencing poverty during and after pregnancy is linked to delayed cognitive development and poor school performance in children (Larson, 2007). Therefore, having access to good quality prenatal care, financial stability, and food security, among many other SDOH, is crucial for optimal health and thriving development.

There is a significant disparity in pregnancy outcomes in the United States based on race and ethnicity (Akinyemi et al., 2022). Indigenous, Black/African American, Latin, and Asian women have higher rates of unemployment and poverty (Chinn et al., 2021; Srinivasan & Guillermo, 2000; Vega et al., 2009). The stresses associated with these two factors have a significant impact on the developing child and maternal health. A healthy pregnancy requires access to quality prenatal care. Consistent prenatal care throughout pregnancy helps identify potential problems and concerns early on that can be prevented or treated and reduces the risk of pregnancy and birth complications.

3.7.1 Healthcare Access and Quality

The World Health Organization (WHO) is striving for a world in which “every pregnant woman, and newborn receives quality care throughout pregnancy, childbirth, and the postnatal period.” A key word in this statement is quality. If you think about it, first not everybody has access to prenatal care and not all prenatal care is created equal. Having access to prenatal care is only half of the equation because the quality of the prenatal care can facilitate a healthy pregnancy, childbirth, and health of a newborn and mother postnatally. Yet, barriers to this care continue to affect many. In this section, first we will discuss access to healthcare and then quality of care.

Although the United States is one of the wealthiest countries in the world, it has the highest maternal mortality rate (26.4/100,000 live births vs 8.4) compared to 10 other high-income nations (Australia, Canada, Denmark, France, Germany, Japan, the Netherlands, Sweden, Switzerland, and the United Kingdom). Additionally, the US has the highest newborn mortality, infant mortality, cesarean rate, and the second highest low birthweight rate compared to these 10 nations (Papanicolas et al., 2018). Finally, the US obtained the 33rd place among world nations on a composite index (Save the Children’s Mothers Index) that includes maternal health, child wellbeing, education, economic security and political participation (Save the Children, 2016).

However, unsurprisingly, these unfavorable maternal and infant indicators are driven by inequitable outcomes of maternity care. Racial and ethnic disparities especially impact Black and Native women and their newborns. Black women are more than three times as likely and Native women more than two times as likely to to experience a pregnancy related death compared to White women (Peterson et al., 2019). Furthermore, 60 percent of pregnancy-related deaths are considered preventable regardless of access and provision of quality care and no difference in preventability in Black and Hispanic women compared to White women (Daw et al., 2017).

Unfortunately, disparities that drive unequitable maternal and infant indicators also include geographic location. Rural women are 9 percent more likely than urban women to experience a composite measure of severe maternal morbidity and mortality (Kozhimannil et al., 2019), and 59 percent more likely to have a substance use disorder diagnosis at birth (Soni et al., 2019). In rural counties, infant, newborn, and post birth mortality rates are higher compared to urban counties (Ely et al., 2018). Finally, the rates of teen births vary up to four times across states, from 7.2 per 1,000 births in the state of Massachusetts to 30.4 in the state of Arkansas (Daw et al., 2017).

As discussed previously, financial stability is an important factor that plays a role in both access and quality of prenatal care. Low income women experience lack of health insurance and or gaps in health insurance coverage (Admon et al., 2021). Therefore, low income pregnant women are less likely to receive prenatal care in their first trimester or postpartum visits compared to women with steady health insurance coverage. While prenatal care can help identify potential pregnancy related complications, postpartum care is also essential for identifying potentially serious and life-threatening complications post birth and weeks after.

Admon and colleagues (2021) found that in a nationally representative sample of 39,378 women with an average age of 27, about 44% were continuously insured, 21% experienced changes between private and Medicaid coverage, 32% had shifted between insurance coverage and no coverage, and more than 2% were continuously without insurance coverage. Additionally, Spanish speaking Hispanic women composed two thirds of the women who experienced no health insurance coverage continuously.

Given the variability in access to care, how can we ensure access to quality care? The WHO defines quality of care as “the extent to which health care services provided to individuals and patient populations improve desired health outcomes. “ To achieve this, health care should be “safe, effective, timely, efficient, equitable, and people-centered.” We can extend the last factor from people-centered to women-centered. Let’s break down each of these factors one by one.

Table 3.1. Variables for Quality Health Care.

Tuncalp et al., 2015

3.7.2 Environmental Risk Factors and Pregnancy Outcomes

Because the developing baby is particularly vulnerable to environmental pollutants, limiting environmental exposures plays a crucial role in a healthy pregnancy. Many epidemiological studies suggest that there is an association between environmental exposures (teratogens) and pregnancy outcomes. Some examples of environmental exposures include air pollution, environmental tobacco smoke, pesticides, solvents, metals, radiation, water contaminants, chemicals, and many others. Potential pregnancy outcomes include pregnancy loss, stillbirth, and congenital abnormalities (Nieuwenhuijsen et al., 2013). However, chemical and non-chemical exposure that have a detrimental effect on maternal health are not equitably distributed across the population (Boyles et al., 2021).

This inequitable distribution contributes to the many disparities observed in health conditions. Racial and ethnic minorities live in largely different not only physical but social environments compared to the majority of the White population (Daw et al., 2017). Furthermore, the exposure to stressors can come from institutional, individual behaviors, and internalized discriminatory policies and practices. This can lead individuals to either a higher or lower risk across the lifespan, including the essential reproductive period.

These conditions can contribute to the disparity in increased risk of adverse maternal health behaviors (increased stress exposure) and outcomes (preeclampsia) (Feinstein et al., 2020; James-Todd et al, 2016). More importantly, environmental risk factors have a stronger impact on the health of racial and ethnic minorities compared to White populations for cardio and metabolic health conditions including obesity, hypertension, type II diabetes mellitus, chronic kidney disease, and cardiovascular disease (James-Todd et al, 2016; Liu et al., 2019; Noor et al., 2019; Varshavsky et al., 2019 ).

A recent review found an association between the effects of synthetic chemicals such as some POPs (e.g., perfluoroalkyl/polyfluoroalkyl substances) and non POPs (i.e., phenols, phthalates, and parabens) with gestational diabetes and non regulated glucose metabolism in pregnant women and other vulnerable populations (Gaston et al., 2020). Moreover, racial and ethnic minority women commonly have a higher body burden of exposures that include consumer products, occupations, and residential environment (James-Todd et al., 2011; McDonald et al., 2019 ). For example, only being able to eat foods that are highly processed because of lack of access to nutritious food or being limited to occupations that have an increased exposure to chemicals.

For example, people living in low-income neighborhoods often have little access to fresh and healthy food. As a result, they consume higher quantities of EDCs (endocrine-disrupting chemicals) in the processed food available at fast-food restaurants, convenience and discount stores. These environments are known as “food deserts” (i.e., lacking access to healthy food) or “food swamps,” (i.e., “swamped” with unhealthy food options) When grocery shopping, people without a lot of money are more likely to purchase cheaper, more chemically loaded consumer products (Ruiz et al., 2018).

A main focus of minority health research is to investigate and identify health burdens of racial and ethnic minority populations stemming from environmental exposures and social disadvantages resulting from discriminatory policies and practices that contribute to maternal health disparities (Duran & Perez-Stable, 2019). For example, pregnant mothers seeking nutritious food for their developing fetus will have to navigate food deserts and food swamps. When they go to the doctor, they will also experience structural discrimination in the form of discriminatory policies and practices. A good example is the experience of Serena Williams, the professional tennis player. Serena has spoken up about the experiences of Black women with the healthcare system in the United States.

Oftentimes, Black women express that they are not listened to and their concerns, signs, and symptoms get ignored. Serena Williams was not the exception. As she wrote, “ “No one was really listening to what I was saying.” The tennis player felt something was wrong after she gave birth to her child. Although she insisted that something was wrong, the nurses continued to dismiss her worries. Finally, her obstetrician listened to her and ordered some tests. Later, they found out that she had developed blood clots in her lungs, which may have resulted in a tragedy, if not treated. Unfortunately, Serena’s experience is all too familiar to many Black women in the US.