Contributor: The Impact of Social Determinants of Health on Maternal Health

Resources exist, but the challenge lies in accessing the right mix of supportive policies, technical assistance, community governance structures, and financing to address the harmful effects of SDOH effectively.

Jayme Ambrose, DNP, RN, CCM, CEO, Adobe Population Health

Addressing the deep-seated impact of social determinants of health (SDOH) on maternal and public health isn't just about identifying the problems—it's about finding the right mix of solutions. While resources and strategies to combat these challenges do exist, effectively leveraging them requires a coordinated approach involving supportive policies, technical assistance, community governance, and sustainable financing.

Social, economic, and environmental conditions in which people live significantly impact health, functionality, and quality of life.¹ SDOH includes financial strain, housing instability, food insecurity, and lack of access to health care and education, all of which exacerbate serious health conditions such as heart disease, stroke, mental health issues, and diabetes.² These factors also negatively impact maternal health from pregnancy through childbirth and postpartum.

Maternal health is a crisis in the US, with death rates rising from 754 in 2019 to 1205 in 2021, reflecting an increase in the maternal mortality rate from 20.1 to 32.9 per 100,000 live births.³ Economic, educational, and geographic barriers delay or prevent prenatal care, increasing risks for preterm birth, low birth weight, and maternal mortality.⁴ Mental health issues are also prevalent, with financial insecurity, lack of social support, and precarious living conditions leading to depression and anxiety during and after pregnancy. Food insecurity doubles the odds of mental health issues in mothers and behavioral issues in children,² and postpartum depression increases the risk of suicide, a leading cause of death during pregnancy and postpartum.³

Other negative SDOH factors include limited or no access to the internet, crowded housing, high housing costs, and lack of high school diplomas among people over 25. Almost 10% of households lack internet access, particularly in rural and tribal areas, limiting educational and economic opportunities and health care delivery via telehealth.⁵

In 2021, over 40 million households spent more than 30% of their income on housing, and that disproportionately high cost of shelter is associated with poor health. More than 10% of adults over the age of 25 lacked a high school diploma or equivalent in 2022, limiting employment prospects and wages, which also increases the risk of chronic conditions and even early death. Approximately 66.2 million people lived below 150% of the poverty level in 2022, with higher risks seen in racial and ethnic minority groups, rural residents, and people with disabilities, all of which limit access to education, employment, health care, and food.

In 2022, 42.3% of the US population identified as a racial or ethnic minority, which is linked to poor health outcomes, higher infant mortality rates, higher blood pressure, and low-quality health care access. Over 7 million single-parent households reported poorer physical and mental health and higher mortality risks, with children in these households more likely to experience food insecurity and depression. As of September 2023, the national unemployment rate was nearly 4%, with higher rates among those negatively impacted by SDOH, correlating with higher risks for chronic conditions like stroke, heart disease, and arthritis.

Chronic conditions such as hypertension, diabetes, and obesity, which are significant risk factors for maternal health, are exacerbated or caused by SDOH. Chronic exposure to social and cultural stressors can lead to miscarriages, preterm births, and preeclampsia.³ More women are becoming pregnant with preexisting conditions, raising the risk of worsening them and developing new ones. This situation is a sad state of affairs when 84% of pregnancy-related deaths are highly preventable.⁴

Strategies for Improvement

Solutions exist to mitigate the impact of SDOH. Promoting healthy aging through healthy eating, physical activity, and managing chronic conditions can help.⁵ Telehealth has been highly effective in improving access to health care, reducing chronic disease factors, and managing existing conditions.⁴ Increasing broadband access through grants or loans to internet service providers, health care centers, and local governments can reduce costs and expand availability. Subsidies and public housing assistance programs can address housing stability and cost burdens. Programs supporting at-risk students transitioning from middle to high school or enabling them to earn college credits while completing high school can improve graduation rates.⁵

"Backbone organizations" can effectively manage community-based partnerships addressing health care, housing, social services, nutritional assistance, job training, and economic development. For example, North Carolina has an NCCARE 360 initiative that connects people with unmet needs stemming from SDOH through a shared technology network, including targeting expectant and new mothers. Other useful funding strategies include "braiding" and "blending" funds from various sources. The ACL and CDC’s National Learning Community supports nearly 60 community care hubs across 32 states, building cross-organizational capacities to address SDOH.²

Resources exist, but the challenge lies in accessing the right combination of supportive policies, technical assistance, community governance structures, and financing to effectively address SDOH's harmful effects.

References

1. Social determinants of health (SDOH) and places data. CDC. Updated November 6, 2023. Accessed July 2, 2024. https://www.cdc.gov/places/social-determinants-of-health-and-places-data/index.html

2. Domestic Policy Council Office of Science and Technology Policy. The US Playbook to Address Social Determinants of Health. The White House; 2023. Accessed July 2, 2024. https://www.whitehouse.gov/wp-content/uploads/2023/11/SDOH-Playbook-3.pdf

3. Girardi G, Longo M, Bremer AA. Social determinants of health in pregnant individuals from underrepresented, understudied, and underreported populations in the United States. Int J Equity Health. 2023;22(1):186. doi:10.1186/s12939-023-01963-x

4. Katella K. Maternal mortality is on the rise: 8 things to know. Yale Medicine. May 22, 2023. Accessed July 2, 2024. https://www.yalemedicine.org/news/maternal-mortality-on-the-rise

5. Social determinants of health. CDC. Updated November 7, 2023. Accessed July 2, 2024. https://www.cdc.gov/places/measure-definitions/social-determinants-of-health/index.html