Association of neighborhood social determinants of health, race and ethnicity, and severe maternal morbidity on the frequency of emergency department visits and preventable emergency department visits among pregnant individuals

Background The relationship between emergency department (ED) use and SDoH (both individual or neighborhood) factors is complex, and critical factors such as racioethnicity and obstetric comorbidities may moderate this relationship among pregnant individuals. The public health implications of this complex relationship are important for pregnant women because frequent ED visits (both non-preventable and preventable) increase the likelihood of adverse maternal and infant health outcomes and resource burden to communities. Methods Our quantitative study analyzed clinical, billing, and census data about pregnant individuals from a Tertiary Medical Center (TMC) between 2017 and 2020. To classify visits as preventable, we used an updated New York University ED algorithm. The address of the patient during their ED visit was linked to an area-level deprivation measure to represent neighborhood SDoH. Race and ethnicity data were extracted from the electronic health record and clinical diagnosis data was extracted for obstetric comorbidity ICD-10 codes related to increased risk of severe maternal morbidity (SMM). The date of a clinical diagnosis was used to determine if a specific set of comorbidities were present during a pregnancy. Other sociodemographic and clinical variables were extracted for model adjustment. A negative binomial regression was used to fit the data (n=13,357) to examine the frequency of ED and preventable ED visits based on neighborhood SDoH, race and ethnicity, obstetric comorbidity, and the interactions of these variables. Results Adjusted model estimates indicated that individuals who identified as non-Hispanic Black experienced higher frequency of ED use across all levels of neighborhood deprivation, and the ED use among non-Hispanic Black individuals in least deprived neighborhoods were higher than or similar to individuals who identified with other racial and ethnic groups who lived in the most deprived neighborhoods. Non-Hispanic Black individuals had the highest frequencies of ED use compared to individuals who identified with other race and ethnic groups whether SMM was present or not, and the frequencies of ED use among non-Hispanic Black individuals with an absence of obstetric comorbidity was higher than individuals who identified with other race and ethnic groups with a comorbidity. Model estimates also indicate that the probabilities of preventable ED visit did not vary race and ethnicity intersected by SDoH. Individuals with obstetric comorbidities had higher probability of a preventable ED visit compared to those not at risk of SMM regardless of different levels of SDoH opportunity. Our study quantifies these differences in estimates between neighborhood SDoH, race and ethnicity, and SMM risk. Conclusions Examination of interventions to address higher ED use among pregnant individuals require an intersectional lens through which policymakers can gain a nuanced perspective on how ED use is influenced by SDoH, race and ethnicity, and risk of SMM among vulnerable individuals. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study did not receive any funding ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Ohio State University IRB gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data used in the study analysis is subject to restrictions as determined by the institutional IRB.