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Health Equity Research Network on Disparities in Maternal-Infant Health Outcomes
The American Heart Association (AHA) announces a Request for Applications (RFA) for the Health Equity Research Network (HERN) on Disparities in Maternal-Infant Health Outcomes.
The United States has the highest maternal mortality rate among industrialized countries, and cardiovascular disease is the leading cause of pregnancy-related mortality in the U.S. (Mehta et al., Circulation, 144:e251, 2021). Major racial disparities exist in maternal health outcomes. Black women experience pregnancy-related death at a rate 2.5 times higher than White women and 3.5 times higher than Hispanic women, and American Indian/Alaska Native women experience pregnancy-related death more than twice as often as White women (Hoyert, NCHS Health E-Stats, 2021). While educational attainment is often a health protective factor, research suggests this may not be the case with maternal mortality. College-educated Black women are still at higher risk than White and Hispanic women with less than a high school diploma, and Black college-educated women are five times as likely to die than White college-educated women (Petersen et al., Morbidity and Mortality Weekly Report, 68(35), 2019; Bond et al., Circ Cardiovasc Qual Outcomes, 14:e007643, 2021).
Structural racism in the healthcare system can impact how Black women are treated during pregnancy and postpartum care (Taylor, Journal of Law, Medicine & Ethics, 48(3), 2020) and the chronic stress associated with racism has been shown to be tied to cardiovascular disease (Churchwell, et al., Circulation, 142: e454, 2020). Research has begun to explore how social determinants of health (SDOH) impact individuals’ risk of cardiovascular disease, and suggests adverse SDOH are linked to higher CVD risk factors (Jilani, et al., Curr Atheroscler Rep, 23(9): 55, 2021; Mannoh, et al., Curr Opin Cardiol, 36(5): 572, 2021), but further research is needed to understand this connection. Geographic disparities also exist, with women living in rural communities experiencing higher mortality rates than women living in urban communities (Harrington, et al., Circulation, 141:e615, 2020).
Racial disparities exist for infant mortality rates as well, with Black babies having an infant mortality rate of 10.8 deaths per 1,000 live births compared to 4.6 deaths for White babies (Ely & Dirscoll, National Vital Statistics Reports, 69(7), 2020). Racism and other chronic stressors also impact birth outcomes, often leading to low birth weight or preterm birth (Braveman, et al., PLoS One, 12: e0186151, 2017), which are the leading causes of infant mortality and often lead to long-term cognitive developmental health issues (Farooqi, et al., PLoS One, 11:e0151819, 2016; Taylor, Semin Perinatol, 40: 529, 2016). Interestingly, new research suggests that when Black newborns are cared for by a Black physician as compared to a White physician, the rate of infant mortality is cut in half (Greenwood, et al., PNAS, 117(35): 21194, 2020). Additional research is needed to more fully understand how structural racism and racial disparities manifest and can be addressed with regard to maternal and infant morbidity and mortality.
Defining additional opportunities for improvements in delivery of care are also needed. For example, cardio-obstetrics is a multidisciplinary field that takes a team approach to addressing cardiovascular disease during pregnancy and can help prevent maternal mortality (Mehta, et al., Circulation, 141, 2020). As an additional example, research suggests doula care is beneficial for improving maternal health outcomes (Bohren, et al., Chochrane Database Syst Rev., 7(7): CD003766, 2017), and in particular, race and/or cultural concordance between doulas and birthing mothers is beneficial in building a trusting relationship and helping to mitigate the institutional biases often faced by Black mothers in the health system (Wint, et al., Health Equity, 3(1): 109, 2019). The ability of many women to access doula care remains insufficient, however (https://www.healthaffairs.org/do/10.1377/forefront.20210525.295915/full/). Further building the evidence base for this and other interventions and approaches to care may facilitate changes in policy resulting in substantially improved outcomes.
In addition to the social and structural factors that impact disparities in maternal health outcomes, biological factors may have an important role. As an example, preeclampsia, a pregnancy-specific disease characterized by high blood pressure, increased protein levels and other factors, occurs in approximately 5% of pregnancies and is a major contributor to mortality and morbidity. The precise mechanism(s) underlying preeclampsia remains unclear, although a number of likely contributing factors have been identified (Chaiworapongsa et al., Nat Rev Nephrol 10(8): 466, 2014). Its prevalence is significantly higher in Black women and in Alaska Native and American Indian women compared to non-Hispanic white women (see Johnson and Louis, Am. J. Obstet. Gynecol doi: 10.1016/j.ajog.2020.07.038, 2020 and references therein). The ability to accurately predict susceptibility to likelihood of mothers developing preeclampsia could minimize these disparities and improve outcomes for all mothers. Whereas there has been some progress in this area, lack of knowledge of biomarkers of preeclampsia and other conditions that increase the likelihood of poor outcomes with pregnancy remains a significant limitation in maternal care (MacDonald et al., EBioMedicine 2022;75:103780).
Pre-proposal Deadline: March 8, 2022
Areas of Interest
GENERAL OVERVIEW – The Health Equity Research Network (HERN) on Disparities in Maternal-Infant Health will be a single Network that will include multiple projects. An overall project plan will be developed by self-identified sites and submitted to the AHA as a coordinated submission. Proposed projects will have a common fundamental theme that will assess pathophysiologic mechanisms, an intervention or approach to the optimization of health outcomes for mothers and/or infants. All aspects of the network application (each Project and the Coordinating Center) will be reviewed as a collective program. The successful Network application will be one wherein each Project and the Coordinating Center are judged to be exemplary, and thus all components will be funded (i.e., either the entire Network [with some possible budgetary adjustments] will be funded, or the entire Network will not be funded).
PROJECTS - Each Network application will include a minimum of three and no more than five projects. Each project will be at a distinct institution, and each will be led by a Project Principal Investigator (PI). Each project must have the necessary research team, required infrastructure and ability to recruit and retain a diverse group of study participants.
The AHA encourages applicant teams to submit innovative intervention or investigative projects that can prevent or reduce poor maternal or infant health outcomes. With the exception that studies must be conducted using human participants and must include interventions, the AHA is not advocating for a particular study topic or design. Below are examples of general themes; this list is not exhaustive and is not meant to direct applicants to a particular approach:
- Identification and assessment of training needs for health professionals who provide care to those giving birth in the United States, including implementation of antiracist policies and practices to promote health equity and eliminate structural racism in health care
- Research to further understand the impact of social determinants of health, structural racism, and chronic stress on cardiovascular disease as it relates to maternal health
Implementation and evaluation of interventions to mitigate the effect of social and structural determinants of health, including racially based discrimination, on maternal and infant health and mortality, including rural and/or other medically underserved communities
- Identification, implementation and evaluation of strategies that incorporate cardiovascular health professionals and integrated care delivery outpatient models (e.g., doulas, midwives, community health workers) in the continuum of care for those giving birth in the United States
- Assessment of the potential role of telemedicine in reducing maternal and infant mortality in populations that have poor access to health care
- Research to understand biological mechanisms as well as clinical and social maternal fertility risk factors, particularly among racial and ethnic diverse people and development of strategic care models to attenuate associated maternal and fetal morbidity and mortality
- Identification of biomarkers that could be predictive in determining likelihood of high-risk pregnancies in susceptible populations
Institutional Eligibility / Location of Work:
AHA awards are limited to U.S.-based non-profit institutions, including medical, osteopathic and dental schools, veterinary schools, schools of public health, pharmacy schools, nursing schools, universities and colleges, public and voluntary hospitals and others that can demonstrate the ability to conduct the proposed research. Applications will not be accepted for work with funding to be administered through any federal institution or work to be performed by a federal employee, except for Veterans Administrations employees.
Eligibility of Coordinating Center PI
- Must hold a doctoral-level degree.
- Must hold a faculty-rank position of any level. This award is not intended for trainees.
Eligibility of Project PIs
- Must hold a doctoral-level degree, or comparable credentials and experience documenting the ability to effectively lead the proposed project.
- Must hold a faculty-rank position of any level, or comparable research-related position from any project application originating from a non-academic institution.