Community-level social determinants of health and pregestational and gestational diabetes

Social Determinants of Health and Diabetes in Pregnancy

Social determinants of health (SDOH) are the conditions in which people are born, grow, work, live, and age. SDOH are systemic factors that may explain, perpetuate, and exacerbate disparities in health outcomes for different populations and can be measured at both an individual and neighborhood or community level (iSDOH, nSDOH). In pregnancy, increasing evidence shows that adverse iSDOH and/or nSDOH are associated with a greater likelihood that diabetes develops, and that when it develops, there is worse glycemic control and a greater frequency of adverse pregnancy outcomes. Future research should not only continue to examine the relationships between SDOH and adverse pregnancy outcomes with diabetes but should determine whether multilevel interventions that seek to mitigate adverse SDOH result in equitable maternal care and improved patient health outcomes for pregnant individuals living with diabetes. · SDOH are conditions in which people are born, grow, work, live, and age.. · SDOH are systemic factors that may explain, perpetuate, and exacerbate disparities in health outcomes.. · SDOH can be measured at the individual and neighborhood level.. · Adverse SDOH are associated with worse outcomes for pregnant individuals living with diabetes.. · Interventions that mitigate adverse SDOH to improve maternal health equity and outcomes are needed..

The impact of social determinants of health on infant and maternal health using a reproductive justice lens

BACKGROUND

Rates of preterm birth, low birth weight, and Neonatal Intensive Care Unit (NICU) admissions continue to rise in the United States (US). Social determinants of health (SDOH) are recognized as significant contributors to infant and maternal health, underscoring the need for use of research frameworks that incorporate SDOH concepts. The Restoring Our Own Through Transformation (ROOTT) theoretical framework is rooted in reproductive justice (i.e. reproductive rights and social justice-based framework) and emphasizes both structural and social determinants as root causes of health inequities. The impact of SDOH on maternal and infant mortality and morbidity can often be traced to structural determinants unique to the US, including slavery, Jim Crow laws, redlining, and the GI Bill.

AIMS

Using data from the Pregnancy Risk Assessment Monitoring System (PRAMS) 8 database, we aimed to evaluate relationships between SDOH (as guided by the ROOTT Framework) and maternal and infant health outcomes.

METHODS

Data were analyzed from 11 states that included the SDOH supplement in their PRAMS 8 data collection. We used bivariate analyses to examine relationships between SDOH measures guided by the ROOTT framework (e.g. abuse during pregnancy, access to prenatal care, housing stability and education) and maternal morbidity (i.e., gestational hypertension and gestational diabetes) and infant outcomes (i.e., preterm birth, NICU admission, breastfeeding). Pre-identified covariates were controlled for in the logistic and linear regression models.

RESULTS

Preterm birth, NICU admission, breastfeeding, and maternal morbidities were significantly associated with SDOH measures linked to structural determinants in the US. Abuse during pregnancy, access to prenatal care, housing, and education were all significantly associated with poorer infant health outcomes in the final regression models. Women who received prenatal care beginning in the 3rd trimester were twice as likely to develop gestational hypertension.

CONCLUSIONS

SDOHs rooted in structural determinants are important predictors of poorer maternal and infant health outcomes. Evaluating health outcomes using a reproductive justice framework reveals modifiable risk factors, including access to stable healthcare, safety, and housing. Comprehensive healthcare provision must ensure early and consistent access to healthcare and resources for safety and housing stability to support maternal and infant health.

Disparities in Diabetes in Pregnancy and the Role of Social Determinants of Health

PURPOSE OF REVIEW

The rates of diabetes in pregnancy (type 1, type 2, and gestational diabetes) are increasing. Diabetes in pregnancy is associated with increased risk for maternal and neonatal complications. Certain groups are disproportionately affected by these complications and this paper reviews the data about disparities in diabetes in pregnancy and explores the social determinants of health (SDoH) underlying these disparities.

RECENT FINDINGS

Rates of diagnosis of gestational diabetes and pregestational diabetes are higher in racial and ethnic minority groups and people with socioeconomic disadvantage. There is higher all cause maternal mortality for Black people compared to White people. Emerging data suggests higher risk for adverse pregnancy outcomes for Black, American Indian, and Hispanic/Latina subjects with diabetes compared to White subjects. Individuals living in neighborhoods with higher poverty and less educational attainment also have higher rates of pregnancy and neonatal complications with diabetes. Diabetes in pregnancy is a complex condition which requires specialty care that can be time-consuming and costly. Individuals with disadvantages in income and employment, food security, social protection and support, and access to affordable and quality health services may be particularly susceptible to adverse outcomes of diabetes in pregnancy. Providers can reduce disparities by recognizing individuals with vulnerabilities in SDoH and tailoring treatment to social context. Equitable access to diabetes technology and postpartum care can also reduce disparities in outcomes.

Predictors of Composite Maternal and Fetal Outcomes among Pregnant Women with Early-Onset Type 2 Diabetes: A Cross-Sectional Study

INTRODUCTION

The most common form of pregestational diabetes in pregnancy is type 2 diabetes, requiring strict metabolic monitoring owing to the risk of adverse pregnancy outcomes. Our study aimed to identify predictors of composite maternal outcome (CMO) and fetal outcome (CFO) separately in pregnant women with early-onset type 2 diabetes (PwEOT2D).

METHODS

The cross-sectional pilot study included 60 PwEOT2D by recording age, socioeconomic determinants, preconception body mass index (pBMI), preconception (pHbA1c) and trimester-specific glycated hemoglobin (HbA1c), gestational weight gain (GWG), and pregnancy outcomes. We defined CMO as at least one of the following: gestational hypertension, preeclampsia, eclampsia, preterm delivery, or emergency section. CFO included at least one of the following: small or large for gestational age, macrosomia, neonatal hypoglycemia, or admission to the neonatal intensive care unit.

RESULTS

CMO was detected in 55% and CFO in 35% of PwEOT2D. The majority of PwEOT2D with CMO lived in suburban areas (73.1%), while those without CMO mostly lived in rural areas (51.9%, p = 0.014). Moreover, PwEOT2D with CMO had comparable pBMI to those without CMO (31.45 ± 6.27 versus 28.99 ± 6.28 kg/m2, p = 0.136). However, PwEOT2D with CMO had higher pHbA1c (7.28 ± 0.95 versus 6.46 ± 0.96%, p = 0.002) and first trimester HbA1c (7.24 ± 1.08 versus 6.42 ± 0.97%, p = 0.003). Similarly, PwEOT2D with CFO had higher pHbA1c (7.84 ± 0.95 versus 6.41 ± 0.67%, p < 0.001) and first trimester (7.29 ± 1.07 versus 6.65 ± 1.07%, p = 0.032) and second trimester HbA1c (6.45 ± 0.87 versus 5.96 ± 0.82%, p = 0.038). Additionally, GWG was higher in the second (4.38 ± 2.01 versus 3.33 ± 1.61 kg, p = 0.032) and third trimester (5.66 ± 2.93 versus 3.89 ± 2.61 kg, p = 0.002) compared with those without CMO. Regression analysis identified pHbA1c, first trimester of pregnancy, and community type as predictors of CMO, while pHbA1c and the occurrence of CMO were predictors of CFO.

CONCLUSIONS

Our results imply that preconception and first trimester of pregnancy HbA1c, as well as community disparities, are predictors of CMO, while the predictors of CFO were only preconception HbA1c and the occurrence of CMO in pregnant women with EOT2D. Therefore, tailoring preventive strategies, followed by achieving and sustaining trimester-specific metabolic control, might improve pregnancy outcomes in women with EOT2D.

Hypertensive disorders in a gestational diabetes cohort from Cape Town, South Africa

INTRODUCTION AND OBJECTIVE

As thresholds for the diagnosis of gestational diabetes mellitus (GDM) become lower, and the prevalence of obesity in society rises, more pregnant women will be diagnosed with GDM and hypertension. Both conditions hold dangers for mother and baby. Our objective was to properly describe this association.

STUDY DESIGN AND OUTCOME MEASURES

This retrospective audit was conducted at the Obstetric High-Risk Clinic at Tygerberg Academic Hospital, Cape Town, South Africa. All patients diagnosed with GDM from 01/01/19 - 31/12/19 were included. The primary aim was to determine the incidence, and different classes of hypertensive disease associated with GDM in this population. The secondary aims were to evaluate associations with the development of hypertensive disorders in women with GDM and to include descriptions of the management, course and complications during the pregnancies, including the early neonatal period. The research was approved by the Ethics Committee of Stellenbosch University.

RESULTS

Of the 274 women with GDM, included in the analysis, 204 (75 %) had concomitant hypertension. Classes of hypertension were chronic hypertension 21 % (58/274), gestational hypertension 26 % (71/274), and pre-eclampsia (de novo and super-imposed) 27 % (75/275). Those without hypertension had significantly lower BMIs: 35 [29-42] vs 41 [34-45] kg/m2 (median [IQR]; p < 0.001). Using ROC curves, BMI at booking had strong associations with chronic and gestational hypertension (p = 0,002; p = 0,001), and pre-eclampsia (p = 0,002). All three intra-uterine deaths (two spontaneous and one iatrogenic) occurred in the GDM + hypertension group.

CONCLUSION

Hypertensive conditions of pregnancy were common amongst a referral-based population with GDM, with BMI being the strongest predictor.

Area Poverty and Adverse Birth Outcomes: An Opportunity for Quality Improvement

OBJECTIVE

To evaluate the association between area poverty and adverse birth outcomes in the diverse birthing population of a large health system.

METHODS

This was a retrospective cohort study using electronic health record and hospital administrative data for pregnant people at nine hospitals within a large health system in the Chicago metropolitan area from 2018 to 2023. Patient addresses were geocoded and categorized by Census tract area percent poor households. Unadjusted and adjusted Poisson regression models, controlling for individual-level risk factors, evaluated the independent association between area poverty and birth outcomes to determine the degree to which this association is attenuated by the inclusion of individual-level factors in the model.

RESULTS

The study included 85,025 pregnant people. Area poverty was associated with sociodemographic factors, including young age, non-Hispanic Black race, Hispanic ethnicity, Medicaid insurance coverage, higher parity, and several comorbid conditions. Area poverty was associated with adverse birth outcomes and demonstrated a gradient effect with increasing area poverty in bivariable analyses. In unadjusted regression analyses, residence in areas with 5.0% or more poverty was associated with severe maternal morbidity, preterm birth, and low birth weight, and residence in areas with 8.0% or higher poverty was associated with neonatal intensive care unit admission. Although these associations persisted in multivariable analysis for severe maternal morbidity and neonatal intensive care unit admission, the associations with preterm birth and low birth weight persisted only for individuals residing in areas of 12.0% or higher poverty when controlling for individual-level risk factors.

CONCLUSION

Area poverty was associated with adverse birth outcomes in this birthing population even when controlling for individual-level risk factors, highlighting the need for system- and community-level quality-improvement interventions.

Association of Community Characteristics as Measured by Social Deprivation Index Score with Prenatal Care and Obstetrical Outcomes

OBJECTIVE

 We aimed to determine the relationships between socioeconomic disadvantage, as measured by the Social Deprivation Index (SDI), and prenatal care (PNC) utilization, obstetrical outcomes, and neonatal complications.

STUDY DESIGN

 All spontaneously conceived singleton deliveries of nulliparous gravida with residence zip code available (n = 4,786) were identified in a population-based database. Deliveries were assigned SDI scores based on preconception zip code. SDI scores (1-100) are a composite measure of seven community demographic characteristics of poverty, education, transportation, employment, and household composition. SDI scores were categorized into quartiles and grouped for analysis (Q1 [n = 1,342], Q2 + 3 [n = 1,752], and Q4 [n = 1,692]) with higher scores indicative of greater disadvantage. Statistical analysis was performed using a generalized linear mixed method.

RESULTS

 Among our cohort, gravida in the lowest (least-deprived) SDI quartile (Q1) were older, had lower prepregnancy body mass indices, and were more likely to receive PNC from a physician specializing in Obstetrics and Gynecology. Gravida residing in the highest (most-deprived) SDI quartile (Q4) attended fewer prenatal visits (mean [standard deviation] 11.17 [2.9]) than those living in Q1 (12.04 [2.3], p < 0.0001). Gravida in Q4 were less likely to receive sufficient PNC compared with those in Q1 (52 vs. 64.2%, p < 0.0001) and were more likely to fail to achieve appropriate gestational weight gain (GWG) (19.6 in Q4 vs. 15.9% in Q1, p < 0.01). No significant differences in composite maternal (CMM) or neonatal morbidity (CNM) were associated with SDI quartile.

CONCLUSION

 Outer quartile social deprivation was associated with higher proportions of primigravida not meeting recommendations for GWG and attending fewer prenatal visits, but it did not affect CMM or CNM. Improving care access and providing nutritional support to all gravida are likely important steps toward health equity.

KEY POINTS

· Neighborhood social deprivation was not associated with composite maternal or neonatal morbidity.. · Community-level deprivation was associated with decreased PNC utilization.. · It is important to understand the underlying disparities that lend to suboptimal patterns of PNC.. · Doing so may inform programs that promote favorable birth outcomes in at-risk communities..

The Association of Food Security With Hypertensive Disorders of Pregnancy: A National Health Interview Survey Analysis

Food security is one of the most researched social determinants of health (SDoH), however, there is a lack of literature on the impact of food security on cardiovascular disease in pregnancy. The primary objective was to examine the association between food security with hypertensive disorders of pregnancy. We performed a cross-sectional analysis of 2019-2022 data from the National Health Interview Survey. The study population included women of childbearing age who were either pregnant or recently pregnant. Logistic regression models were developed to examine the association between food security and hypertensive disorders of pregnancy. Of the 1635 women included in the analysis, the rate of hypertensive disorders  of pregnancy was 11.1% and the rate of low and very low food security was 5.3% and 4.0%, respectively. The prevalence was 5.8% for hyperlipemia, 0.3% for cardiovascular disease, and 10.5% for diabetes mellitus. The odds of hypertensive disorders of pregnancy were statistically significantly increased among women with low food security compared to women with high food security (odds ratio [OR] 2.40, 95% confidence interval [CI]: 1.19-4.81) after adjusting for age, race, ethnicity, insurance status, body mass index, hyperlipidemia, diabetes mellitus, and cardiovascular disease. Further studies are needed to elucidate the causes of hypertensive disorders of pregnancy and interventions to address including the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and food pantries, as it may be more feasible to address issues of food security among pregnant women.

Diabetic Ketoacidosis and Adverse Outcomes Among Pregnant Individuals With Pregestational Diabetes in the United States, 2010-2020

OBJECTIVE

To assess the frequency of, risk factors for, and adverse outcomes associated with diabetic ketoacidosis (DKA) at delivery hospitalization among individuals with pregestational diabetes (type 1 and 2 diabetes mellitus) and secondarily to evaluate the frequency of and risk factors for antepartum and postpartum hospitalizations for DKA.

METHODS

We conducted a serial, cross-sectional study using the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project Nationwide Readmissions Database from 2010 to 2020 of pregnant individuals with pregestational diabetes hospitalized for delivery. The exposures were 1) sociodemographic and clinical risk factors for DKA and 2) DKA. The outcomes were DKA at delivery hospitalization, maternal morbidity (nontransfusion severe maternal morbidity (SMM), critical care procedures, cardiac complications, acute renal failure, and transfusion), and adverse pregnancy outcomes (preterm birth, hypertensive disorders of pregnancy, and cesarean delivery) and secondarily DKA at antepartum and postpartum hospitalizations.

RESULTS

Of 392,796 deliveries in individuals with pregestational diabetes (27.2% type 1 diabetes, 72.8% type 2 diabetes), there were 4,778 cases of DKA at delivery hospitalization (89.1% type 1 diabetes, 10.9% type 2 diabetes). The frequency of DKA at delivery hospitalization was 1.2% (4.0% with type 1 diabetes, 0.2% with type 2 diabetes), and the mean annual percentage change was 10.8% (95% CI, 8.2-13.2%). Diabetic ketoacidosis at delivery hospitalization was significantly more likely among those who had type 1 diabetes compared with those with type 2 diabetes, who were younger in age, who delivered at larger and metropolitan hospitals, and who had Medicaid insurance, lower income, multiple gestations, and prior psychiatric illness. Diabetic ketoacidosis during the delivery hospitalization was associated with an increased risk of nontransfusion SMM (20.8% vs 2.4%, adjusted odds ratio [aOR] 8.18, 95% CI, 7.20-9.29), critical care procedures (7.3% vs 0.4%, aOR 15.83, 95% CI, 12.59-19.90), cardiac complications (7.8% vs 0.8%, aOR 8.87, 95% CI, 7.32-10.76), acute renal failure (12.3% vs 0.7%, aOR 9.78, 95% CI, 8.16-11.72), and transfusion (6.2% vs 2.2%, aOR 2.27, 95% CI, 1.87-2.75), as well as preterm birth (31.9% vs 13.5%, aOR 2.41, 95% CI, 2.17-2.69) and hypertensive disorders of pregnancy (37.4% vs 28.1%, aOR 1.11, 95% CI, 1.00-1.23). In secondary analyses, the overall frequency of antepartum DKA was 3.1%, and the mean annual percentage change was 4.1% (95% CI, 0.3-8.6%); the overall frequency of postpartum DKA was 0.4%, and the mean annual percentage change was 3.5% (95% CI, -1.6% to 9.6%). Of 3,092 antepartum hospitalizations among individuals with DKA, 15.7% (n=485) had a recurrent case of DKA at delivery hospitalization. Of 1,419 postpartum hospitalizations among individuals with DKA, 20.0% (n=285) previously had DKA at delivery hospitalization. The above risk factors for DKA at delivery hospitalization were similar for DKA at antepartum and postpartum hospitalizations.

CONCLUSION

The frequency of DKA at delivery hospitalization and antepartum hospitalizations for DKA increased between 2010 and 2020 among deliveries in individuals with pregestational diabetes in the United States. Diabetic ketoacidosis is associated with an increased risk of maternal morbidity and adverse pregnancy outcomes. Risk factors for DKA at delivery were similar to those for DKA during the antepartum and postpartum periods.

Integrating Social Determinants of Health in Machine Learning-Driven Decision Support for Diabetes Case Management: Protocol for a Sequential Mixed Methods Study

BACKGROUND

The use of both clinical factors and social determinants of health (SDoH) in referral decision-making for case management may improve optimal use of resources and reduce outcome disparities among patients with diabetes.

OBJECTIVE

This study proposes the development of a data-driven decision-support system incorporating interactions between clinical factors and SDoH into an algorithm for prioritizing who receives case management services. The paper presents a design for prediction validation and preimplementation assessment that uses a mixed methods approach to guide the implementation of the system.

METHODS

Our study setting is a large, tertiary care academic medical center in the Deep South of the United States, where SDoH contribute to disparities in diabetes-specific hospitalizations and emergency department (ED) visits. This project will develop an interpretable artificial intelligence model for a population with diabetes using SDoH and clinical data to identify which posthospitalization cases have a higher likelihood of subsequent ED use. The electronic health record data collected for the study include demographics, SDoH, comorbidities, hospitalization-related factors, laboratory test results, and medication use to predict posthospitalization ED visits. Subsequently, a mixed methods approach will be used to validate prediction outcomes and develop an implementation strategy from insights into patient outcomes from case managers, clinicians, and quality and patient safety experts.

RESULTS

As of December 2023, we had abstracted data on 174,871 inpatient encounters between January 2018 and September 2023, involving 89,355 unique inpatients meeting inclusion criteria. Both clinical and SDoH data items were included for these patient encounters. In total, 85% of the inpatient visits (N=148,640) will be used for training (learning from the data) and the remaining 26,231 inpatient visits will be used for mixed-methods validation (testing).

CONCLUSIONS

By integrating a critical suite of SDoH with clinical data related to diabetes, the proposed data-driven risk stratification model can enable individualized risk estimation and inform health professionals (eg, case managers) about the risk of patients' upcoming ED use. The prediction outcome could potentially automate case management referrals, helping to better prioritize services. By taking a mixed methods approach, we aim to align the model with the hospital's specific quality and patient safety considerations for the quality of patient care and the optimization of case management resource allocation.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56049.

Association between density of food retailers and fitness centers and gestational diabetes mellitus in Eastern Massachusetts, USA: population-based study

Background

Few studies have investigated the relationship between the food and physical activity environment and odds of gestational diabetes mellitus (GDM). This study quantifies the association between densities of several types of food establishments and fitness centers with the odds of having GDM.

Methods

The density of supermarkets, fast-food restaurants, full-service restaurants, convenience stores and fitness centers at 500, 1000 and 1500 m (m) buffers was counted at residential addresses of 68,779 pregnant individuals from Eastern Massachusetts during 2000-2016. The 'healthy food index' assessed the relative availability of healthy (supermarkets) vs unhealthy (fast-food restaurants, convenience stores) food retailers. Multivariable logistic regression quantified the cross-sectional association between exposure variables and the odds of having GDM, adjusting for individual and area-level characteristics. Effect modification by area-level socioeconomic status (SES) was assessed.

Findings

In fully adjusted models, pregnant individuals living in the highest density tertile of fast-food restaurants had higher GDM odds compared to those living in the lowest density tertile (500 m: odds ratio (OR):1.17 95% CI: [1.04, 1.31]; 1000 m: 1.33 95% CI: [1.15, 1.53]); 1500 m: 1.18 95% CI: [1.01, 1.38]). Greater residential density of supermarkets was associated with lower odds of GDM (1000 m: 0.86 95% CI: [0.74, 0.99]; 1500 m: 0.86 95% CI: [0.72, 1.01]). Similarly, living in the highest fitness center density tertile was associated with decreased GDM odds (500 m:0.87 95% CI: [0.76, 0.99]; 1500 m: 0.89 95% CI: [0.79, 1.01]). There was no evidence of effect modification by SES and no association found between the healthy food index and GDM odds.

Interpretation

In Eastern Massachusetts, living near a greater density of fast-food establishments was associated with higher GDM odds. Greater residential access to supermarkets and fitness centers was associated with lower the odds of having GDM.

Funding

NIH.

Environmental Justice Index and adverse pregnancy outcomes

BACKGROUND

The Environmental Justice Index is a tool released by the Centers for Disease Control and Prevention that quantifies and ranks the environmental burden and social vulnerability of each census tract. Racial and ethnic disparities in adverse pregnancy outcomes are well established. The relative contributions of individual (person-level) and environmental (neighborhood-level) risk factors to disease prevalence remain poorly understood.

OBJECTIVE

This study aimed to determine whether the Environmental Justice Index is associated with adverse pregnancy outcomes after adjustment for individual clinical and sociodemographic risk factors.

STUDY DESIGN

This was a retrospective cross-sectional study of all patients who delivered a singleton newborn at ≥23 weeks of gestation between January 2019 and February 2022 at 7 hospitals within a large academic health system in New York. Patients were excluded if their home address was not available, if the address could not be geocoded to a census tract, or if the census tract did not have corresponding Environmental Justice Index data. Patients were also excluded if they had preexisting diabetes or hypertension. For patients who had multiple pregnancies during the study period, only the first pregnancy was included for analysis. Clinical and demographic data were obtained from the electronic medical record. Environmental Justice Index score, the primary independent variable, ranges from 0 to 1. Higher Environmental Justice Index scores indicate communities with increased cumulative environmental burden and increased social vulnerability. The primary outcome was adverse pregnancy outcome, defined as the presence of ≥1 of any of the following conditions: hypertensive disorders of pregnancy, gestational diabetes, preterm birth, fetal growth restriction, low birthweight, small for gestational age newborn, placental abruption, and stillbirth. Multivariable logistic regression was performed to investigate the relationship between Environmental Justice Index score and adverse pregnancy outcome, adjusting for potential confounding variables, including body mass index group, race and ethnicity group, advanced maternal age, nulliparity, public health insurance, and English as the preferred language.

RESULTS

A total of 65,273 pregnancies were included for analysis. Overall, adverse pregnancy outcomes occurred in 37.6% of pregnancies (n=24,545); hypertensive disorders of pregnancy (13.4%) and gestational diabetes (12.2%) were the most common adverse pregnancy outcome conditions. On unadjusted analysis, the strongest associations between Environmental Justice Index score and individual adverse pregnancy outcome conditions were observed for stillbirth (odds ratio, 1.079; 95% confidence interval, 1.025-1.135) and hypertensive disorders of pregnancy (odds ratio, 1.052; 95% confidence interval, 1.042-1.061). On multivariable logistic regression, every 0.1 increase in Environmental Justice Index score was associated with 1.4% higher odds of adverse pregnancy outcome (adjusted odds ratio, 1.014; 95% confidence interval, 1.007-1.021). The strongest associations with adverse pregnancy outcomes were observed with well-established clinical and social risk factors, including class 3 obesity (adjusted odds ratio, 1.710; 95% confidence interval, 1.580-1.849; reference: body mass index <25 kg/m2) and certain race and ethnicity groups (reference: non-Hispanic White), particularly Asian and Pacific Islander (adjusted odds ratio, 1.817; 95% confidence interval, 1.729-1.910), and non-Hispanic Black (adjusted odds ratio, 1.668; 95% confidence interval, 1.581-1.760) people.

CONCLUSION

Environmental Justice Index score is positively associated with adverse pregnancy outcomes, and most strongly associated with stillbirth and hypertensive disorders of pregnancy. Geospatial analysis with Environmental Justice Index may help to improve our understanding of health inequities by identifying neighborhood characteristics that increase the risk of pregnancy complications.

Maternal responsibility and omission of complexity: an exploration of the portrayal of gestational diabetes mellitus in Danish written media

OBJECTIVES

Gestational diabetes mellitus (GDM) has implications for the future health of both mother and offspring, and there is a risk that mothers are held responsible and blamed for their own and their offspring's long-term health. The media plays a significant role in shaping public perceptions of health. Therefore, our study aimed to investigate how GDM and women with GDM are portrayed in Danish written media.

DESIGN

We identified written newspaper articles reporting on GDM from 2018 to 2019 and analysed them using thematic network analysis and elements from critical discourse analysis.

RESULTS

In total, 130 articles were included in the analysis. Four themes emerged: (1) ways of introducing GDM, (2) descriptions of causes and prevention of GDM, (3) descriptions of consequences of GDM and (4) value-laden descriptions of GDM. GDM was often mentioned in relation to other conditions or factors and with lack of differentiation. Maternal responsibility was emphasised via oversimplified descriptions of causal relations, descriptions of individual agency and no emphasis on structural causes and preventive measures. GDM was positioned as resulting in 'bad pregnancies' using value-laden wordings.

CONCLUSION

We identified various aspects of how GDM is portrayed in written media. The findings signal the importance of clear, nuanced and respectful communication on GDM, including conveying the complexity of the condition and the role of structural factors.