Association Between Severity of COVID-19 and Social Determinants of Health with Adverse Pregnancy Outcomes in a Study of Mother–Infant Pairs in Los Angeles, California

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Title: Association between severity of COVID-19 and social determinants of health with adverse pregnancy outcome in a longitudinal study of Mother-Infant pairs in Los Angeles, California

 

Major concerns:

1. [Page 2 Line 89] The authors mention, enrollment criteria as “aged 16 or older” in this section. This is discrepant with that mentioned in the texts below [Page 3 Line 95]. Please clarify.
2. [Page 2 Line 89] What happens to mothers who were asymptomatic and were not tested for infection by RT-PCR or serology? I would assume they would not have been in the study, introducing a selection (ascertainment) bias. Please address this as a limitation.
3. [Page 5 Lines 199-200] The authors state that “rest lived elsewhere in southern California”. Were these individuals excluded from Figure 1? If so, please state it explicitly. Also, how were zip code-related SDOH factors obtained for this subset of cohort and analyzed in the paper? Please clarify.
4. [Page 6 Line 207] The authors state that 34.4% were vaccinated against COVID-19 prior to delivery. There is existing literature to suggest COVID-19 vaccination having a negative impact on reproductive health. Is there a possibility that COVID-19 vaccination could be a confounder or a mediator? I would recommend addressing this question. If unable to do so using the study data, discuss it as a limitation of the study.
5. [Figure 2] There is so much overlap in the data points between the APO Yes/No categories in the plot. It is hard to say that APO is common in those living with low income. Also, is it possible that the significant p-value is just noise. Please clarify.
6. [Figure 3] Would recommend the authors show this “per capita income” as more of a gradient as opposed to binary above and below categories.
7. [Figure 5] It is unclear from the figure as to what it is showing. Also, why is race used as a proxy for SDOH and not others. Race has not been significant in the study findings presented. So, unclear why the authors have chosen Race. Please clarify.
8. [Page 11 Line 276-277] This sentence if not justified by the study findings. Table 2 clearly shows that race, particularly black/African american was not significant (p=0.11). Would recommend removing this interpretation of the results.

 

 

Minor concerns:

1. I would recommend the authors proofread the draft for inappropriate placement of punctuations
2. [Page 2 Line 79] I would reframe the sentence for clarity
3. The authors grouped race and ethnicity together. But these are not mutually exclusive groups. How were Hispanic white or Hispanic black categorized? Please include a sentence to describe the categorization.
4. [Table 1] Labeling of “N” and “%” for COVID-19 severity is missing.
5. [Page 11 Lines 284-285] This sentence is not justified by the results. Please cite.

 

Author Response

Please see attachment

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This study examines the association between social determinants of health and both COVID-19 severity and adverse pregnancy outcomes in a cohort of pregnant women in Los Angeles County, California. The authors utilized data from the UCLA COVID-19 Outcomes Mother-Infant Pair prospective cohort study to analyze how factors such as race/ethnicity, income, and healthcare access influenced pregnancy outcomes among women with confirmed SARS-CoV-2 infection. The findings suggest that economic disparities may contribute to worse maternal outcomes and that SDOH moderated the relationship between COVID-19 severity and APOs, particularly among Black women.

The study addresses a crucial public health issue by linking social determinants to pregnancy outcomes in the context of COVID-19. The methodology is well-defined, and the authors used the STROBE guidelines to ensure comprehensive reporting. The data collection process, including the use of electronic health records and geospatial analysis of ZIP codes, is well described.

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Minor revision

The manuscript could benefit from a clearer explanation of the primary hypotheses and how they were tested. While the study explores multiple associations, the core research question could be more explicitly framed.

The introduction provides a good background but could be more focused on how this study differs from prior work on SDOH and maternal health during COVID-19.

The study states that it used the STROBE guidelines, which is commendable. However, a more detailed description of sample selection, loss to follow-up, and potential biases in recruitment would be helpful.

The discussion acknowledges the role of economic disparity in health outcomes but should elaborate on other SDOH domains (e.g., social support, education level).

The study states that ZIP code was a stronger predictor of APOs than race. This is an important finding, but it could be discussed in the context of existing literature.

Limitations are well-addressed, but additional discussion on potential biases in self-reported race and ZIP code as proxies for SDOH would be beneficial.

This study makes a valuable contribution to understanding the intersection of social determinants of health and maternal outcomes during COVID-19. While the findings are robust, addressing the statistical, methodological, and interpretational concerns highlighted above will further strengthen the manuscript.

Author Response

Please see the attachment

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

This paper focuses on the impact of social determinants on COVID-19 disease severity during pregnancy in the population of LA. The study has a robust methodology, the limitations are well outlined and the text is easy to follow, with results being clearly presented. The findings of this study are relevant not only for the evaluated population, but for similar areas with socio-economic disparity. A minor comment would be that Figure 1 is missing it's caption. 

Author Response

Dear Reviewer,

Thank you for your review on our manuscript submitted. We appreciate the constructive comments and suggestions made. We hope we have addressed all concerned and noted our response and changes below, in red. We would like to sincerely thank you for your time and thoughtful response to our paper.

Reviewer 3

A minor comment would be that Figure 1 is missing it's caption. 

We appreciate this catch! We have updated the figure with the proper caption.

Again, thank you for your time and review.

Reviewer 4 Report

Comments and Suggestions for Authors

This study evaluated the association between social determinants of health and both COVID-19 severity and adverse pregnancy outcomes (APOs) in a cohort of pregnant women in Los Angeles

1. The study design was cross-sectional (line 83). The term "longitudinal" is used in the title, to indicate that the women on whom the study was conducted came from a pregnant COVID-19 cohort. However, the use of the term suggests that this study is longitudinal and should be avoided.
2. The authors have used proxy for SDOH, medical insurance type for health care access, ZIP code to determine economic neighborhood disparities, and self-reported race/ethnicity for social/community context. The use of these measures, although reasonable, should be considered a limitation of the study that the authors can report and discuss.
3. Very minor change, line 316, commas are misplaced

Author Response

Please see the attachment

Author Response File: Author Response.pdf