Environmental and Social Health Determinants of Pregnancy Outcomes Related to COVID-19 Pandemic

The COVID-19 pandemic is uniquely challenging for pregnant women. Adverse pregnancy outcomes (e.g. gestational diabetes, pre-eclampsia & eclampsia, preterm birth, antepartum depression, and postpartum depression) are likely worsened by the COVID-19 pandemic. A few recent studies have shown that ambient fine particulate matter < 2.5 µm (PM2.5) and nitrogen dioxide (NO2) may increase the susceptibility to SARS- CoV-2 infection, severity of illness, and mortality in the general population. It is reasonable to hypothesize that ambient air pollution may likely increase the risk of adverse pregnancy outcomes related to COVID-19 pandemic. But the effect of air pollution coupled with maternal comorbidities and sociodemographic determinants on adverse pregnancy outcomes related to COVID-19 pandemic has not been established. This time-sensitive competing revision will extend the scope of the parent study of Air Pollution and Pregnancy Complications in Complex Urban Environments: Risks, Heterogeneity, and Mechanisms (R01ES030353) by examining associations of air pollution with major adverse maternal outcomes related to COVID-19 pandemic among the large diverse pregnant women population from the electronic health record database of Kaiser Permanente Southern California (Aim 1), and further studying the role of SARS-CoV-2 infection, preexisting comorbidity, and sociodemographic factors on these associations (Aim 2). We have a multi-disciplinary team with expertise in environmental exposure assessment, environmental epidemiology, maternal-fetal medicine, and biostatistics to examine the specific aims. To our knowledge, this is the first study to determine the association of air pollution with adverse pregnancy outcomes related to COVID-19 pandemic. The proposed study has several major innovations and methodological strengths, including 1) large (67,000 deliveries during the COVID-19 pandemic and 45,000 deliveries before the pandemic) and diverse population (the majority from racial and ethnic minority groups); 2) high quality, prospectively-recorded, and time-resolved individual-level clinical data for both outcomes and potential effect modifiers, including COVID-19 case data based on universal screening of pregnant women; 3) investigation associations between air pollution exposure and antepartum and postpartum depression; 4) analysis of effect modification by SARS-CoV-2 infection, comorbidity, and sociodemographic factors; 5) high spatiotemporal resolution PM2.5 exposure estimates based on dense ground-level senor network data; and 6) thorough examination of potential confounding from individual-level maternal factors (e.g. smoking, physical activity) and other environment exposures (e.g. heatwave and green space). This study will generate new knowledge about the impact of air pollution on adverse maternal outcomes related to COVID-19 pandemic. As air pollution is a modifiable risk factor, this study can help advance interventions to reduce the adverse pregnancy outcomes related to COVID-19 pandemic.