Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA (Dr Robbins); Center for Maternal and Child Health Equity and Advocacy, Eastern Virginia Medical School Norfolk, VA (Dr Robbins).
Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL (Drs Szychowski, Tita, and Sinkey); Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL (Dr Szychowski).
Am J Obstet Gynecol MFM. 2023 Feb;5(2):100788. doi: 10.1016/j.ajogmf.2022.100788. Epub 2022 Oct 27.
Cardiomyopathy causes more than a third of late postpartum pregnancy-related deaths in the United States, and racial disparities in outcomes among pregnant individuals with cardiomyopathy exist. Underlying community factors may contribute to disparities in peripartum cardiomyopathy outcomes.
This study aimed to identify the geographic distribution of and disparities in peripartum cardiomyopathy outcomes, hypothesizing that patients living in communities with higher social vulnerability may have worse outcomes.
This was a retrospective cohort study of patients with peripartum cardiomyopathy per the National Heart, Lung, and Blood Institute definition from January 2000 to November 2017 at a single center, excluding those with a post office box address as a post office box address may not reflect the census tract in which a patient resides. Severe peripartum cardiomyopathy (vs less severe peripartum cardiomyopathy) was defined as ejection fraction <30%, death, intensive care unit admission, left ventricular assist device or implantable cardioverter defibrillator placement, or transplant. The US census tract for the patient's address was linked to the Centers for Disease Control and Prevention Social Vulnerability Index, a 0 to 1 scale of a community's vulnerability to external stresses on health, with higher values indicating greater vulnerability. The Social Vulnerability Index includes social factors divided into socioeconomic, household composition, minority status, and housing type and transportation themes. The Social Vulnerability Index and Social Vulnerability Index components were compared among patients by peripartum cardiomyopathy severity.
Of 95 patients in the original cohort, 5 were excluded because of the use of a post office box address. Of the remaining 90 patients, 56 met severe peripartum cardiomyopathy criteria. At baseline, individuals with and without severe peripartum cardiomyopathy had similar ages, marital status, payor type, tobacco use, gestational age at delivery, and mode of delivery; however, individuals with severe peripartum cardiomyopathy were more likely to be Black (vs White) (59% vs 29%; P<.007) and less likely to recover ejection fraction (EF) to ≥55% by 12 months (36% vs 62%; P=.02) than individuals with less severe peripartum cardiomyopathy. Patients with severe peripartum cardiomyopathy were more likely to live in areas with a higher Social Vulnerability Index (0.51 vs 0.31; P=.002) and with more residents who were unemployed, impoverished, without a high school diploma, in single-parent households, of minority status, without a vehicle, and in institutionalized group quarters than patients with less severe peripartum cardiomyopathy. The median income was lower in communities of individuals with severe peripartum cardiomyopathy than in communities of individuals with less severe peripartum cardiomyopathy.
Patients with severe peripartum cardiomyopathy outcomes were more likely to live in communities with greater social vulnerability than patients with less severe peripartum cardiomyopathy outcomes. To reduce disparities and maternal mortality rates, resources may need to be directed to socially vulnerable communities.
在美国，心肌病导致超过三分之一的产后晚期妊娠相关死亡，并且患有心肌病的孕妇在结局方面存在种族差异。潜在的社区因素可能导致围产期心肌病结局的差异。
本研究旨在确定围产期心肌病结局的地理分布和差异，并假设居住在社会脆弱性较高的社区的患者可能会有更差的结局。
这是一项单中心的回顾性队列研究，纳入了 2000 年 1 月至 2017 年 11 月期间符合美国国立心肺血液研究所定义的围产期心肌病患者，不包括使用邮箱地址的患者（因为邮箱地址可能无法反映患者居住的普查区）。严重围产期心肌病（与轻度围产期心肌病相比）定义为射血分数<30%、死亡、入住重症监护病房、左心室辅助装置或植入式心脏复律除颤器的放置或移植。患者地址的美国普查区与疾病预防控制中心社会脆弱性指数相关联，该指数是衡量社区对健康外部压力脆弱性的 0 到 1 标度，数值越高表示脆弱性越大。社会脆弱性指数包括分为社会经济、家庭构成、少数族裔地位和住房类型和交通主题的社会因素。比较了严重围产期心肌病和轻度围产期心肌病患者的社会脆弱性指数和社会脆弱性指数成分。
在最初的 95 名患者中，有 5 名因使用邮箱地址而被排除在外。在剩余的 90 名患者中，有 56 名符合严重围产期心肌病标准。在基线时，患有严重和轻度围产期心肌病的患者年龄、婚姻状况、支付类型、吸烟状况、分娩时的胎龄和分娩方式相似；然而，患有严重围产期心肌病的患者更可能是黑人（59%比 29%；P<.007），并且不太可能在 12 个月时射血分数（EF）恢复到≥55%（36%比 62%；P=.02），而患有轻度围产期心肌病的患者。患有严重围产期心肌病的患者更可能生活在社会脆弱性指数较高的地区（0.51 比 0.31；P=.002），并且有更多的失业者、贫困人口、没有高中文凭、单亲家庭、少数族裔、没有交通工具和居住在机构化群体宿舍的居民，而患有轻度围产期心肌病的患者。患有严重围产期心肌病的患者所在社区的中位收入低于患有轻度围产期心肌病的患者所在社区。
患有严重围产期心肌病结局的患者更有可能生活在社会脆弱性较大的社区，而患有轻度围产期心肌病结局的患者则不然。为了减少差异和孕产妇死亡率，资源可能需要投向社会脆弱性社区。
