Disentangling effects of ethnicity, deprivation, and payment source on obstetric outcomes in American primigravidae: A structural equation model of observational data

Abstract

Background: Women from ethnic minorities have worse obstetric outcomes. Possible reasons for this are (1) social deprivation; (2) different standards of obstetric care; and (3) intrinsic ethnic differences. Here I aim to disentangle (1)-(3). Methods: I constructed two path models of causal links between parental ethnicity and obstetric outcomes. The first, "no-racism", model estimated independent causal effects of ethnicity, deprivation and payment source on pregnancy and birth outcomes. The second "realistic" model additionally tested how far deprivation and payment source may mediate effects of ethnicity. Analyses of the models used Bayesian estimation. I analysed both the full sample of complete data and a random 1% sample. Findings: Data were complete for 762786 births. The "no-racism" model did not fit the data, but the "realistic" model fitted adequately. It indicated that ethnicity, social deprivation, and private funding for care all adversely affected outcomes: (i) African American and Hispanic ethnicity caused deprivation; (ii) deprivation increased pregnancy hypertension, shortened gestation and reduced birthweight; (iii) private funding directly increased pregnancy hypertension and indirectly shortened gestation; (iv) participation in the Supplemental Nutrition Program for Women, Infants and Children (WIC) counteracted adverse effects of deprivation. (v) independently of (i)-(iv), ethnic-minority parents had shorter gestation and lighter babies. Interpretation: Deprivation largely accounts for adverse obstetric outcomes in ethnic minorities. Private funding may also worsen pregnancy hypertension, but WIC improved outcomes. The uniformity of adverse birth outcomes for all ethnic minorities suggests that these result from a common factor, which may be systemic racism. Policies to reduce deprivation and increase government-funded care could importantly improve obstetric outcomes, irrespective of ethnicity.