Document Type



Importance Persistent racial and ethnic disparities in severe maternal morbidity (SMM) in the US remain a public health concern. Structural racism leaves women of color in a disadvantaged situation especially during COVID-19, leading to disproportionate pandemic afflictions among racial and ethnic minority women.

Objective To examine racial and ethnic disparities in SMM rates before and during the COVID-19 pandemic and whether the disparities varied with level of Black residential segregation.

Design, Setting, and Participants A statewide population-based retrospective cohort study used birth certificates linked to all-payer childbirth claims data in South Carolina. Participants included women who gave birth between January 2018 and June 2021. Data were analyzed from December 2021 to February 2022.

Exposures Exposures were (1) period when women gave birth, either before the pandemic (January 2018 to February 2020) or during the pandemic (March 2020 to June 2021) and (2) Black-White residential segregation (isolation index), categorizing US Census tracts in a county as low (<40%), medium (40%-59%), and high (≥60%).

Main Outcomes and Measures SMM was identified using International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes developed by the US Centers for Disease Control and Prevention. Multilevel logistic regressions with an interrupted approach were used, adjusting for maternal-level and facility-level factors, accounting for residential county-level random effects.

Results Of 166 791 women, 95 098 (57.0%) lived in low-segregated counties (mean [SD] age, 28.1 [5.7] years; 5126 [5.4%] Hispanic; 20 523 [21.6%] non-Hispanic Black; 62 690 [65.9%] White), and 23 521 (14.1%) women (mean [SD] age, 28.1 [5.8] years; 782 [3.3%] Hispanic; 12 880 [54.8%] non-Hispanic Black; 7988 [34.0%] White) lived in high-segregated areas. Prepandemic SMM rates were decreasing, followed by monthly increasing trends after March 2020. On average, living in high-segregated communities was associated with higher odds of SMM (adjusted odds ratio [aOR], 1.61; 95% CI, 1.06-2.34). Black women regardless of residential segregation had higher odds of SMM than White women (aOR, 1.47; 95% CI, 1.11-1.96 for low-segregation; 2.12; 95% CI, 1.38-3.26 for high-segregation). Hispanic women living in low-segregated communities had lower odds of SMM (aOR, 0.48; 95% CI, 0.25-0.90) but those living in high-segregated communities had nearly twice the odds of SMM (aOR, 1.91; 95% CI, 1.07-4.17) as their White counterparts.

Conclusions and Relevance Living in high-segregated Black communities in South Carolina was associated with racial and ethnic SMM disparities. During the COVID-19 pandemic, Black vs White disparities persisted with no signs of widening gaps, whereas Hispanic vs White disparities were exacerbated. Policy reforms on reducing residential segregation or combating the corresponding structural racism are warranted to help improve maternal health.

Digital Object Identifier (DOI)


© 2022 Hung P et al. JAMA Network Open. This is an open access article distributed under the terms of the CC-BY License, which permits unrestricted use, distribution, and reproduction in any medium. You are not required to obtain permission to reuse this article content, provided that you credit the author and journal.

APA Citation

Hung, P., Liu, J., Norregaard, C., Shih, Y., Liang, C., Zhang, J., Olatosi, B., Campbell, B. A., & Li, X. (2022). Analysis of Residential Segregation and Racial and Ethnic Disparities in Severe Maternal Morbidity Before and During the COVID-19 Pandemic. JAMA Network Open, 5(10), e2237711.