Disparities in Severe Maternal Morbidity and Mortality Elizabeth - PowerPoint PPT Presentation

Disparities in Severe Maternal Morbidity and Mortality Elizabeth Howell MD, MPP Director, Blavatnik Family Women’s Health Research Institute Professor, Depts of Population Health Science & Policy; Ob/Gyn Icahn School of Medicine at Mount Sinai Funded by NIH #R01MD007651 1

Erica Garner 2

Disparities in Maternal Mortality • Minorities represent half of all US births and racial/ethnic minorities suffer higher maternal mortality rates • Black women 3 to 4 times more likely to die than white women – largest disparity among population perinatal health measures • Native Americans, some Asians, some Latinas also have elevated rates CDC Pregnancy Mortality Surveillance System at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html 3

United States Pregnancy-related Mortality by Race, Ethnicity, Nativity 2000-2006 45 39.9 US Born 40 Deaths/100,00 live births Fore ign Born 34.1 35 30 25 20 15 12.3 11.7 10.9 10.3 10.3 10 8.4 5 0 Wh ite Black Hi spa nic Asia n/ Pacific Isla nde r Creanga, Obstet Gynecol. 2012 Aug;120(2 Pt 1):261-8. 4

Maternal Mortality (per 100,000 ) Moaddab, et al. Health Care Disparity and State-Specific Pregnancy-Related Mortality in the United States, 2005-2014. Obstet Gynecol. 2016;128:869- 75. 5

Disparities More Pronounced in New York City • Blacks 12 times more likely to die – Widening of gap since 2001-2005 – Increased gap driven by 45% decreased mortality among whites • Asian/Pacific Islanders 4x as likely to die • Latinas 3x as likely to die New York City Department of Health and Mental Hygiene (2015). Pregnancy Associated Mortality in New York City, 2006-2010. 6

Severe Maternal Morbidity (SMM) • For every maternal death, 100 women experience severe obstetric morbidity • Life-threatening diagnosis or life-saving procedure – organ failure (e.g. renal, liver), shock, amniotic embolism, eclampsia, septicemia, cardiac events – ventilation, transfusion, hysterectomy • Significant racial/ethnic disparities exist Callaghan. Obstet Gynecol 2012;120:1029-36. 7

Severe Maternal Morbidity Rates in New York City 4. 5% 4.2% 4. 0% 3. 5% 3. 0% 2.7% 2. 5% Black La tina 2. 0% 1.5% Whit e 1. 5% 1. 0% 0. 5% 0. 0% Black La tina Whit e Howell Am J Obstet Gynecol. 2016 Aug;215(2):143-52; Howell. Obstet Gynecol. 2017 Feb;129(2):285-294.

New York City Department of Health and Mental Hygiene (2016). Severe Maternal Morbidity in New York City, 2008–2012. New York, NY. 9

Health status: comorbidities (e.g. HTN, DM, obesity, depression); Patient Factors Figure 1: Pathways to Racial and Ethnic - Socio-demographics: age, Disparities in Severe Maternal Morbidity education, poverty, & Mortality insurance, marital status, employment, language, literacy Preconception - Knowledge, beliefs, health Care behaviors Pregnancy complications - Psychosocial: stress, self- Race/ Ethnicity efficacy, social support Community/ Neighborhood Outcomes - Community, social network Severe Postpartum Antenatal Maternal - Neighborhood: crime, Care Care Morbidity poverty, built environment, & Mortality housing Provider Factors - Knowledge, experience, Delivery & implicit bias, cultural Hospital competence, communi- Care cation System Factors - Access to high quality care, Howell EA. Clin Obstet Gynecol. 2018 transportation, structural Jan 16. [Epub] 10 10 racism, policy

Health status: comorbidities (e.g. HTN, DM, obesity, depression); Patient Factors Figure 1: Pathways to Racial and Ethnic - Socio-demographics: age, Disparities in Severe Maternal Morbidity education, poverty, & Mortality insurance, marital status, employment, language, literacy Preconception - Knowledge, beliefs, health Care behaviors Pregnancy complications - Psychosocial: stress, self- Race/ Ethnicity efficacy, social support Community/ Neighborhood Outcomes - Community, social network Severe Postpartum Antenatal Maternal - Neighborhood: crime, Care Care Morbidity poverty, built environment, & Mortality housing Provider Factors - Knowledge, experience, Delivery & implicit bias, cultural Hospital competence, communi- Care cation System Factors - Access to high quality care, Howell EA. Clin Obstet Gynecol. 2018 transportation, structural Jan 16. [Epub] 11 11 racism, policy

Hospital Quality and Disparities • Nearly one-half of severe events / maternal deaths preventable • Hospital quality important contributing factor • Site of care receiving increasing attention as mechanism for disparities • Growing body of research suggests racial/ethnic women deliver in lower quality hospitals Geller. Womens Health Issues 2006 Jul-Aug;16(4):176-88; Howell. Am J Obstet Gynecol. 2016 Jan;214(1):122.e1-e9. Howell Obstet & Gynecol 2017; Creanga 12 12 AJOG 2014;

Research on Delivery Hospital and US Disparities • In US, 75% of all black deliveries occur in a quarter of all hospitals vs. 18% of white deliveries • Hospitals that disproportionately care for black deliveries – have higher risk adjusted SMM rates for both blacks and whites – perform worse than other hospitals on delivery- related indicators Howell. Am J Obstet Gynecol. 2016 Jan;214(1):122.e1-e9; Creanga AJOG 2014 Dec;211(6):647.e1-16. 13 13

Distribution of Black and White Deliveries at Black-serving Hospitals in US Cumulative Percentage of Deliveries 100% 82% 80% 60% 50% 40% 26% 24% 16% 20% 2% 0% High Medium Low (N=279) (N=1106) (N=4102) Black White Howell. Am J Obstet Gynecol. 2016 Jan;214(1):122.e1-e9 14 14

Distribution of Black and White Deliveries at Black-serving Hospitals in US Cumulative Percentage of Deliveries 100% Much higher rates of maternal 82% morbidity for black and white 80% moms 60% 50% 40% 26% 24% 16% 20% 2% 0% High Medium Low (N=279) (N=1106) (N=4102) Black White Howell. Am J Obstet Gynecol. 2016 Jan;214(1):122.e1-e9 15 15

Delivery Hospital and NYC Disparities • Phase 1 - Examine risk-adjusted severe maternal morbidity and extent to which hospital quality contributes to racial / ethnic disparities in SMM • Phase 2 – Hospital qualitative interviews to examine safety and culture, quality improvement, and other factors associated with high quality care • Phase 3 – Focus groups with moms • Phase 4 – Dissemination; promotion of best practices * Funded by NIH #R01MD007651; Howell Am J Obstet Gynecol. 2016 Aug;215(2):143-52; Howell. Obstet Gynecol. 2017 Feb;129(2):285-294. 16 16

Phase 1 Methods • Vital Statistics linked with SPARCS for all New York City deliveries (2011-2013) • CDC algorithm to identify severe morbidity • Mixed-effects logistic regression to calculate risk-standardized severe maternal morbidity rates (SSMMR) for each hospital • Ranked hospitals based on SSMMR • Assessed black-white differences and Hispanic- white differences in delivery location 17 17

Hospital Quality and NYC Disparities 7% 6% maternal morbidity (%) Risk standardized 5% 4% RSSMM 3% 2% 1% 0% Hospitals ranked from lowest to highest Observed rates: 0.6% to 11.5%; Risk standardized rates: 0.8% to 5.7% 18 18

Hospital Quality and NYC Disparities 7% Low Medium High 6% maternal morbidity (%) Morbidity Morbidity Morbidity Risk standardized 5% 4% RSSMM 3% 2% 1% 0% Hospitals ranked from lowest to highest morbidity Observed rates: 0.6% to 11.5%; Risk standardized rates: 0.8% to 5.7% 19 19

Deliveries by Race and Risk- standardized Hospital Morbidity Hospital Group by RSSMM* Low Medium High Black (%) 23 39 37 White (%) 65 17 18 Hispanic (%) 33 38 29 Howell Am J Obstet Gynecol. 2016 Aug;215(2):143-52; Howell. Obstet Gynecol. 2017 Feb;129(2):285-294 20 20

Deliveries by Race and Risk- standardized Hospital Morbidity Hospital Group by RSSMM* Low Medium High Black (%) 23 39 37 White (%) 65 17 18 Hispanic (%) 33 38 29 Howell Am J Obstet Gynecol. 2016 Aug;215(2):143-52; Howell. Obstet Gynecol. 2017 Feb;129(2):285-294 21 21

Summary • Wide variation in risk-standardized maternal morbidity among NYC hospitals • Higher rates of severe maternal morbidity among blacks and Latinas partially due to differences in delivery location 22 22

Friday, November 4, 2016 12:30 p.m. Eastern Dial In: 888.863.0985 Conference ID: 49389917

Alliance for Innovation on Maternal Health • Cooperative agreement between ACOG and Maternal Child Health Bureau • National data-driven maternal safety and quality improvement initiative • Patient safety bundles to standardize delivery care • Reaches over one-half US births by partnering with states, DOH, health systems 24 24

Alliance for Innovation on Maternal Health: Focus on Disparities • One of the first professional bodies to address disparities • Unique perspective - addressing disparities under a patient safety umbrella • Raises awareness among health systems, departments of health, hospitals, and clinicians who care for pregnant and postpartum women 25 25

Bundle Development • Multidisciplinary working group • Review of literature – Disparities frameworks – Drivers of disparities and relative contributions • Examples from all of medicine – Effective interventions to reduce disparities