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

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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

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Erica Garner

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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

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United States Pregnancy-related Mortality by Race, Ethnicity, Nativity 2000-2006

10.3 39.9 10.3 10.9 8.4 34.1 12.3 11.7

5 10 15 20 25 30 35 40 45 Wh ite Black Hi spa nic Asia n/ Pacific Isla nde r US Born Fore ign Born Deaths/100,00 live births

Creanga, Obstet Gynecol. 2012 Aug;120(2 Pt 1):261-8.

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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

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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.

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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.

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Severe Maternal Morbidity Rates in New York City

4.2% 2.7% 1.5%

0. 0%
0. 5%
1. 0%
1. 5%
2. 0%
2. 5%
3. 0%
3. 5%
4. 0%
4. 5%

Black La tina Whit e 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.

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

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Patient Factors

Socio-demographics: age,

education, poverty, insurance, marital status, employment, language, literacy

Knowledge, beliefs, health

behaviors

Psychosocial: stress, self-

efficacy, social support Outcomes Severe Maternal Morbidity & Mortality Preconception Care Antenatal Care Delivery & Hospital Care Postpartum Care Figure 1: Pathways to Racial and Ethnic Disparities in Severe Maternal Morbidity & Mortality

Race/ Ethnicity

Community/ Neighborhood

Community, social network
Neighborhood: crime,

poverty, built environment, housing Health status: comorbidities (e.g. HTN, DM, obesity, depression); Pregnancy complications Provider Factors

Knowledge, experience,

implicit bias, cultural competence, communication System Factors

Access to high quality care,

transportation, structural racism, policy Howell EA. Clin Obstet Gynecol. 2018 Jan 16. [Epub]

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Patient Factors

Socio-demographics: age,

education, poverty, insurance, marital status, employment, language, literacy

Knowledge, beliefs, health

behaviors

Psychosocial: stress, self-

efficacy, social support Outcomes Severe Maternal Morbidity & Mortality Preconception Care Antenatal Care Delivery & Hospital Care Postpartum Care Figure 1: Pathways to Racial and Ethnic Disparities in Severe Maternal Morbidity & Mortality

Race/ Ethnicity

Community/ Neighborhood

Community, social network
Neighborhood: crime,

poverty, built environment, housing Health status: comorbidities (e.g. HTN, DM, obesity, depression); Pregnancy complications Provider Factors

Knowledge, experience,

implicit bias, cultural competence, communication System Factors

Access to high quality care,

transportation, structural racism, policy Howell EA. Clin Obstet Gynecol. 2018 Jan 16. [Epub]

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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

AJOG 2014;

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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.

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Distribution of Black and White Deliveries at Black-serving Hospitals in US

24% 50% 26% 2% 16% 82% 0% 20% 40% 60% 80% 100% High Medium Low

Cumulative Percentage of Deliveries

Black White

(N=279) (N=1106) (N=4102)

Howell. Am J Obstet Gynecol. 2016 Jan;214(1):122.e1-e9

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Distribution of Black and White Deliveries at Black-serving Hospitals in US

24% 50% 26% 2% 16% 82% 0% 20% 40% 60% 80% 100% High Medium Low

Cumulative Percentage of Deliveries

Black White

(N=279) (N=1106) (N=4102)

Much higher rates of maternal morbidity for black and white moms

Howell. Am J Obstet Gynecol. 2016 Jan;214(1):122.e1-e9

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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.

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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

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0% 1% 2% 3% 4% 5% 6% 7%

Risk standardized maternal morbidity (%)

RSSMM

Hospitals ranked from lowest to highest

Observed rates: 0.6% to 11.5%; Risk standardized rates: 0.8% to 5.7%

Hospital Quality and NYC Disparities

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0% 1% 2% 3% 4% 5% 6% 7%

Risk standardized maternal morbidity (%)

RSSMM

Low Morbidity Medium Morbidity High Morbidity

Hospitals ranked from lowest to highest morbidity

Observed rates: 0.6% to 11.5%; Risk standardized rates: 0.8% to 5.7%

Hospital Quality and NYC Disparities

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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

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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

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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

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Friday, November 4, 2016 12:30 p.m. Eastern

Dial In: 888.863.0985 Conference ID: 49389917

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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

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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

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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

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Disparities

Cultural competent communication

Literacy Language Fragmentation Bias Comorbidity

Inter-institutional differences

Education Poverty Institutional racism Environment

Disparities Bundle Framework

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Disparities Bundle Themes

Communication

– Patient education (culturally competent) – Shared decision-making

Systemic racism – implicit bias
Culture of equity
Lack of measurement and benchmarking

– Accurate measurement of race, ethnicity, language – Disparity dashboard

Care fragmentation

– Importance throughout reproductive life

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Four Domains of Patient Safety Bundles

Readiness
Recognition
Response
Reporting/Systems Learning

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Reduction of Peripartum Racial/Ethnic Disparities http://safehealthcareforeverywoman.org/patient-safety- bundles/reduction-of-peripartum-racialethnic-disparities

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https://www.vox.com/identities/2018/1/11/16879984/serena-williams-childbirth-scare- black-women

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ProPublica and NPR story - Nothing Protects Black Women From Dying in Pregnancy and Childbirth

Dec 7, 2017 “In the more than 200 stories of African-American mothers that ProPublica and NPR have collected over the past year, the feeling of being devalued and disrespected by medical providers was a constant theme. The young Florida mother-to-be whose breathing problems were blamed on obesity when in fact her lungs were filling with fluid and her heart was failing. The Arizona mother whose anesthesiologist assumed she smoked marijuana because of the way she did her hair. The Chicago-area businesswoman with a high-risk pregnancy who was so upset at her doctor’s attitude that she changed OB-GYNs in her seventh month, only to suffer a fatal postpartum stroke. Over and over, black women told of medical providers who equated being African American with being poor, uneducated, noncompliant and

unworthy. “Sometimes you just know in your bones when someone feels

contempt for you based on your race,” said one Brooklyn woman who took to bringing her white husband or in-laws to every prenatal visit.”

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THANK YOU

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