1) The outcome I am interested in is prenatal diagnosis of fetal congenital heart disease. Prenatal diagnosis of the most common birth defect has been found to be beneficial in many regards not only for the fetal outcome but also for the maternal outcome. It also provides crucial information that can affect decision making for that pregnancy. Although our technology and awareness of congenital heart disease in the obstetric and pediatric community has increased prenatal diagnosis rates of CHD remain low and are impacted by several of the structural elements that are mentioned in the WHO chapter. For example, Peiris et al conducted a study to assess the impact of socioeconomic position and medical insurance on prenatal diagnosis of CHD in the Boston area (Peiris V et al, 2009). They performed this analysis by creating a SES composite score based on several structural elements including income, occupation and level of education attained. Although the analysis did not distinguish between these individual components, they found that lower composite SES score (based on census tract), was associated with lower rates of prenatal diagnosis. These findings suggest that these structural elements lead to less access to advanced medical services and less robust obstetrical screening practices resulting in fewer referrals for a fetal echocardiogram and diagnosis of CHD prenatally. Interestingly this same paper identified that the single most important determinant of prenatal diagnosis of CHD was insurance status. Those with public insurance had lower rates of prenatal diagnosis. This can be thought of as an intermediary determinant with regard to looking at the health system as a social determinant of health. In addition, one can invoke material circumstances in the form of transportation as an influence on prenatal diagnosis. Individuals with low income levels and lack of social support may not have the means to obtain transportation to obtain health care in tertiary medical centers where advanced medical services such as a fetal echocardiogram are provided.
2) In the article quoted above, neighborhood was addressed as an important contributor to this outcome. By utilizing the subject’s address to place them in census tracts based on census data, this captures information about one’s neighborhood rather than ones individual socioeconomic status. As an example, a neighborhood far from tertiary medical centers may have lack of transportation and this lack of access to these centers to receive specialized services. Because this outcome is relevant to women’s reproductive health and access to care for pregnant women, past socioeconomic experiences can play a role in this outcome. For example, parental education level can impact a pregnant women’s motivation to obtain prenatal care and have access to advanced medical services.