{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T02:25:01Z","timestamp":1787019901081,"version":"build-2736575974"},"reference-count":56,"publisher":"Public Library of Science (PLoS)","issue":"8","license":[{"start":{"date-parts":[[2024,8,12]],"date-time":"2024-08-12T00:00:00Z","timestamp":1723420800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Georgia CTSA NIH","award":["UL1-TR002378"],"award-info":[{"award-number":["UL1-TR002378"]}]},{"name":"Georgia CTSA NIH","award":["UL1-TR002378"],"award-info":[{"award-number":["UL1-TR002378"]}]},{"DOI":"10.13039\/100000001","name":"National Science Foundation","doi-asserted-by":"publisher","award":["DGE-2039655"],"award-info":[{"award-number":["DGE-2039655"]}],"id":[{"id":"10.13039\/100000001","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Georgia Tech H. Milton Stewart School of Industrial and Systems Engineering","award":["Harold R. and Mary Anne Nash Endowment"],"award-info":[{"award-number":["Harold R. and Mary Anne Nash Endowment"]}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Objectives<\/jats:title>\n<jats:p>To determine how pre-existing conditions contribute to racial disparities in adverse maternal outcomes and incorporate these conditions into models to improve risk prediction for racial minority subgroups.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Study design<\/jats:title>\n<jats:p>We used data from the \u201cNulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b)\" observational cohort study. We defined multimorbidity as the co-occurrence of two or more pre-pregnancy conditions. The primary outcomes of interest were severe preeclampsia, postpartum readmission, and blood transfusion during pregnancy or up to 14 days postpartum. We used weighted Poisson regression with robust variance to estimate adjusted risk ratios and 95% confidence intervals, and we used mediation analysis to evaluate the contribution of the combined effects of pre-pregnancy conditions to racial\/ethnic disparities. We also evaluated the predictive performance of our regression models by racial subgroup using the area under the receiver operating characteristic curve (AUC) metric.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>In the nuMoM2b cohort (n = 8729), accounting for pre-existing conditions attenuated the association between non-Hispanic Black race\/ethnicity and risk of severe preeclampsia. Cardiovascular and kidney conditions were associated with risk for severe preeclampsia among all women (aRR, 1.77; CI, 1.61\u20131.96, and aRR, 1.27; CI, 1.03\u20131.56 respectively). The mediation analysis results were not statistically significant; however, cardiovascular conditions explained 36.6% of the association between non-Hispanic Black race\/ethnicity and severe preeclampsia (p = 0.07). The addition of pre-pregnancy conditions increased model performance for the prediction of severe preeclampsia.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>Pre-existing conditions may explain some of the association between non-Hispanic Black race\/ethnicity and severe preeclampsia. Specific pre-pregnancy conditions were associated with adverse maternal outcomes and the incorporation of comorbidities improved the performance of most risk prediction models.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0306206","type":"journal-article","created":{"date-parts":[[2024,8,12]],"date-time":"2024-08-12T17:26:06Z","timestamp":1723483566000},"page":"e0306206","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":7,"title":["Racial\/ethnic differences in pre-pregnancy conditions and adverse maternal outcomes in the nuMoM2b cohort: A population-based cohort study"],"prefix":"10.1371","volume":"19","author":[{"given":"Meghan E.","family":"Meredith","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4073-6165","authenticated-orcid":true,"given":"Lauren 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Gynecology"},{"key":"pone.0306206.ref017","doi-asserted-by":"crossref","first-page":"271.e1","DOI":"10.1016\/j.ajog.2019.06.025","article-title":"A comorbidity-based screening tool to predict severe maternal morbidity at the time of delivery.","volume":"221","author":"SR Easter","year":"2019","journal-title":"Am J Obstet Gynecol"},{"key":"pone.0306206.ref018","doi-asserted-by":"crossref","first-page":"957","DOI":"10.1097\/AOG.0b013e3182a603bb","article-title":"Development of a Comorbidity Index for Use in Obstetric Patients.","volume":"122","author":"BT Bateman","year":"2013","journal-title":"Obstetrics and Gynecology"},{"key":"pone.0306206.ref019","doi-asserted-by":"crossref","first-page":"440","DOI":"10.1097\/AOG.0000000000004022","article-title":"An Expanded Obstetric Comorbidity Scoring System for Predicting Severe Maternal Morbidity.","volume":"136","author":"SA Leonard","year":"2020","journal-title":"Obstetrics and Gynecology"},{"key":"pone.0306206.ref020","article-title":"The Interplay of Hypertension and Anemia on Pregnancy Outcomes.","author":"A Johnson","year":"2023","journal-title":"Cureus"},{"key":"pone.0306206.ref021","doi-asserted-by":"crossref","first-page":"1158","DOI":"10.1097\/AOG.0000000000002937","article-title":"Racial and ethnic disparities in the incidence of severe maternal morbidity in the United States, 2012\u20132015.","volume":"132","author":"LK Admon","year":"2018","journal-title":"Obstetrics and Gynecology"},{"key":"pone.0306206.ref022","first-page":"402","volume-title":"Med Care","author":"AR Qui\u00f1ones","year":"2021"},{"key":"pone.0306206.ref023","doi-asserted-by":"crossref","first-page":"366","DOI":"10.1016\/j.ssmph.2017.03.007","article-title":"Education, race\/ethnicity, and multimorbidity among adults aged 30\u201364 in the National Health Interview Survey.","volume":"3","author":"V Johnson-Lawrence","year":"2017","journal-title":"SSM Popul 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Sci"},{"key":"pone.0306206.ref027","doi-asserted-by":"crossref","first-page":"115","DOI":"10.1016\/j.socscimed.2012.11.031","article-title":"A systematic review of studies examining the relationship between reported racism and health and wellbeing for children and young people.","volume":"95","author":"N Priest","year":"2013","journal-title":"Soc Sci Med"},{"key":"pone.0306206.ref028","article-title":"Multimorbidity patterns across race\/ethnicity as stratified by age and obesity.","volume":"12","author":"M Alshakhs","year":"2022"},{"key":"pone.0306206.ref029","first-page":"2021.08.24.21262142","volume-title":"Data Preparation of the nuMoM2b Dataset","author":"A Goretsky","year":"2021"},{"key":"pone.0306206.ref030","doi-asserted-by":"crossref","first-page":"539.e1","DOI":"10.1016\/j.ajog.2015.01.019","article-title":"A description of the methods of the Nulliparous Pregnancy Outcomes Study: monitoring mothers-to-be (nuMoM2b).","volume":"212","author":"DM Haas","year":"2015","journal-title":"Am J Obstet Gynecol"},{"key":"pone.0306206.ref031","doi-asserted-by":"crossref","first-page":"681","DOI":"10.1002\/(SICI)1097-0258(19990330)18:6<681::AID-SIM71>3.0.CO;2-R","article-title":"Multiple imputation of missing blood pressure covariates in survival analysis","volume":"18","author":"S van Buuren","year":"1998","journal-title":"STATISTICS IN MEDICINE Statist Med"},{"key":"pone.0306206.ref032","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1097\/AOG.0000000000001805","article-title":"Association Between Sleep-Disordered Breathing and Hypertensive Disorders of Pregnancy and Gestational Diabetes Mellitus.","volume":"129","author":"FL Facco","year":"2017","journal-title":"Obstetrics and Gynecology"},{"key":"pone.0306206.ref033","article-title":"Preeclampsia: Risk factors, diagnosis, management, and the cardiovascular impact on the offspring.","volume":"8","author":"R Fox","year":"2019","journal-title":"J Clin Med"},{"key":"pone.0306206.ref034","unstructured":"How Does CDC Identify Severe Maternal Morbidity? | CDC n.d. https:\/\/www.cdc.gov\/reproductivehealth\/maternalinfanthealth\/smm\/severe-morbidity-ICD.htm (accessed April 27, 2022)."},{"key":"pone.0306206.ref035","doi-asserted-by":"crossref","first-page":"113.e1","DOI":"10.1016\/j.ajog.2016.01.174","article-title":"A multi-state analysis of postpartum readmissions in the United States.","volume":"215","author":"MA Clapp","year":"2016","journal-title":"Am J Obstet Gynecol"},{"key":"pone.0306206.ref036","first-page":"10:2235042X20981185","article-title":"The association between clusters of chronic conditions and psychological well-being in younger and older people-A cross-sectional, population-based study from the Lolland-Falster Health Study, Denmark.","author":"LH Tang","year":"2020","journal-title":"J Comorb"},{"key":"pone.0306206.ref037","doi-asserted-by":"crossref","first-page":"100420","DOI":"10.1016\/j.ajogmf.2021.100420","article-title":"Severe maternal morbidity and mortality during delivery hospitalization of class I, II, III, and super obese women.","volume":"3","author":"MH Platner","year":"2021","journal-title":"Am J Obstet Gynecol MFM"},{"key":"pone.0306206.ref038","doi-asserted-by":"crossref","first-page":"1","DOI":"10.18637\/jss.v059.i05","article-title":"mediation: R Package for Causal Mediation Analysis.","volume":"59","author":"D Tingley","year":"2014","journal-title":"J Stat Softw"},{"key":"pone.0306206.ref039","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/1471-2105-12-77","article-title":"pROC: An open-source package for R and S+ to analyze and compare ROC curves","volume":"12","author":"X Robin","year":"2011","journal-title":"BMC Bioinformatics"},{"key":"pone.0306206.ref040","doi-asserted-by":"crossref","DOI":"10.1038\/s41598-019-41383-y","article-title":"A risk stratification tool for hospitalisation in Australia using primary care data.","volume":"9","author":"S Khanna","year":"2019","journal-title":"Sci Rep"},{"key":"pone.0306206.ref041","author":"M Kuhn","year":"2023","journal-title":"Package \u201ccaret\u201d Title Classification and Regression Training."},{"key":"pone.0306206.ref042","author":"D Tingley","journal-title":"mediation: R Package for Causal Mediation Analysis. n.d"},{"key":"pone.0306206.ref043","doi-asserted-by":"crossref","first-page":"435.e1","DOI":"10.1016\/j.ajog.2013.11.039","article-title":"Racial and ethnic disparities in severe maternal morbidity: a multistate analysis, 2008\u20132010.","volume":"210","author":"AA Creanga","year":"2014","journal-title":"Am J Obstet Gynecol"},{"key":"pone.0306206.ref044","doi-asserted-by":"crossref","first-page":"30","DOI":"10.1016\/j.annepidem.2019.02.007","article-title":"Racial and ethnic disparities in severe maternal morbidity prevalence and trends.","volume":"33","author":"SA Leonard","year":"2019","journal-title":"Ann Epidemiol"},{"key":"pone.0306206.ref045","doi-asserted-by":"crossref","first-page":"1460","DOI":"10.1097\/AOG.0000000000000735","article-title":"Racial and Ethnic Disparities in Maternal Morbidity and Obstetric Care.","volume":"125","author":"WA Grobman","year":"2015","journal-title":"Obstetrics and Gynecology"},{"key":"pone.0306206.ref046","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1016\/j.preghy.2018.01.006","article-title":"Severe pre-eclampsia among pregnant women with sickle cell disease and HIV","volume":"11","author":"J Prophet","year":"2018","journal-title":"Pregnancy 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Gynecol"},{"key":"pone.0306206.ref050","doi-asserted-by":"crossref","first-page":"305.e1","DOI":"10.1016\/j.ajog.2021.03.041","article-title":"Angiogenic markers and their longitudinal change for predicting adverse outcomes in pregnant women with chronic hypertension","volume":"225","author":"J Binder","year":"2021","journal-title":"Am J Obstet Gynecol"},{"key":"pone.0306206.ref051","doi-asserted-by":"crossref","first-page":"390.e1","DOI":"10.1016\/j.ajog.2018.08.034","article-title":"Maternal age and risk for adverse outcomes.","volume":"219","author":"JJ Sheen","year":"2018","journal-title":"Am J Obstet Gynecol"},{"key":"pone.0306206.ref052","article-title":"Maternal Morbidity Predicted by an Intersectional Social Determinants of Health Phenotype: A Secondary Analysis of the NuMoM2b Dataset.","author":"EN Erickson","year":"2022","journal-title":"Reprod 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