The Ingram/Spellacy Society was founded in 2010 as the alumni group of Ob/Gyn residents, fellows and faculty of the University of South Florida (USF). The purpose of the Society is to share knowledge and promote support for the USF Department in improving the quality of Ob/Gyn care through education and research. Since its inception, the Society has funded regional lectures and financially supported University of South Florida residents while on electives away from Tampa. The Society has always had close ties with ACOG and is honored to support this annual lectureship at the ACOG District XII 2019 Annual District Meeting.
Maternal Child Health Inequity Haywood L. Brown, MD Professor Obstetrics and Gynecology Associate Dean University South Florida District XII ACOG
Objectives At the conclusion of this presentation the participant will be able to: • Discuss health equity and the impact on disparity in the context of maternal health • Emphasize the impact of bias on maternal outcome for individuals from vulnerable populations at the clinical, operational and system levels • Discuss health policy implications for support or lack there of on the quality of maternity child care in the US
Disclosure • Merck • Manual • Merck for Mother’s Global Advisory Board • Up to Date • Contributor to publications
Definitions • Disparity (Healthy People 2010) • the quantity that separates a group from a reference point on a particular measure of health that is expressed in terms of a rate, proportion, mean, or some other quantitative measure • often measured from the most favorable group rate • Health inequity (Boston Public Health Commission) • difference in health that is not only unnecessary and avoidable but, in addition, are considered unfair and unjust • rooted in social injustices that make some population groups more vulnerable to poor health than other groups.
TRUST, Research, Ethics and health disparities • TUSKEGEE • US Public Health Service Tuskegee Untreated Syphilis Study in Negro Men • Over 40 years lost to follow-up only 17% • 1100 paper published between 1934-1974 Research, Ethics and Health Care & Penicillin
Contributors to health and health care inequities Health system factors • Health services organization, financing, delivery • Health care organizational culture, QI Structural factors • Poverty/wealth • Unemployment Patient-level factors Provider factors • Stability of housing Clinical encounter •Beliefs and preferences • Food security •Knowledge and attitudes •Provider communication •Race/ethnicity, culture, family • Racism •Competing demands •Cultural competence •Education and resources •Implicit/explicit biases •Biology Adapted from Kilbourne et al, AJPH 2006
Contributors to health and health care inequities Health system factors • Health services organization, financing, delivery • Health care organizational culture, QI Patient-level factors Provider factors Clinical encounter •Beliefs and preferences •Knowledge and attitudes •Provider communication •Race/ethnicity, culture, family •Competing demands •Cultural competence •Education and resources •Implicit/explicit biases •Biology Structural factors • Poverty/wealth • Unemployment • Stability of housing • Food security • Racism Adapted from Kilbourne et al, AJPH 2006
Racial/ethnic disparities in Ob/Gyn AI/AN Asian Black Hispanic White Disparities in health outcomes Infertility in last 12 months -- 10 12 9 7 (% of women) Unintended pregnancy (% -- -- 69 56 42 of pregnancies) Preterm birth (% of LB) 14 10 17 12 11 Fetal death (/1,000 live -- -- 11 5 5 births+ fetal deaths) Maternal death (/100,000 -- 10 33 10 11 live births) Gonorrhea (/100,000 96 18 570 -- 24 population) ACOG CO Breast cancer deaths 16 12 31 15 22 #649 (/100,000 population)
Trust gaps • ETIOLOGY OF DISPARITIES IN MATERNAL MORTALITY “When Landrum complained about how she was feeling more forcefully at the appointment, she recalls, her doctor told her to lie down — and calm down.”
U.S. M Maternal al a and I Infan ant Mortal ality U.S. has higher maternal and infant mortality rates than other wealthy countries: • Ranks 19 th of 20 in child mortality • Ranks > 21th in maternal mortality
“Hidden causes” of maternal mortality Koch, 2016
Maternal Mortality is Preventable Main et al. Obstet Gynecol 2015;125(4):938-947
Vulnerable populations • US has higher maternal mortality than Iran, Libya and Turkey • US maternal mortality 2x greater than Canada • Childbirth number 1 reason for hospitalization in the US • For every maternal death 50-100 near miss morbidities • 60 maternal deaths postpartum • Black women die at rate of 3 to 4 times that of white women in the US
Disparities in cesarean delivery Role of patient-provider communication? Role of perception of litigiousness? Role of implicit provider bias? Bryant et al, 2010
Infant Mortality Wealthy Countries
Preterm Birth Report 2016
Prematurity Disparity • Surgeon General’s Conference (O&G 2009) • Psychosocial and Behavior Consideration • Research on the effects of race, racism, and social injustice for African Americans must be a priority as they bear the highest burden of prematurity • Cross Cutting Issues and Conclusion • Dramatic effect of race, ethnicity, and socioeconomic status on the incidence and severity of preterm birth must stimulate policymakers and funders to implement comprehensive and sustained efforts to eliminate social inequity
FIMR
Rural Hospital Closures • Many of those hospitals in the South in states that did not expand Medicaid as of January 2017. • 82% of rural hospital closures (no Medicaid expansion) • Rural Southeastern communities with measurable health disparities for chronic conditions • Diabetes • Hypertension • obesity
Preventable Maternal Mortality • Leading causes of maternal death for non-Hispanic black women • Cardiomyopathy (14.0%) • Cardiovascular and coronary conditions (12.8%) • Preeclampsia/eclampsia (11.6%) • Hemorrhage (10.5%) • Embolism (9.3%) • Deaths with the higher degree of preventability • Cardiovascular and coronary disease ( 68.2%) • Hemorrhage (70%) • Metz TD, Obstet Gynecol 2018;132:1040-5.
Maternal Mortality Postpartum Childbirth Figure 1. Percentage of Maternal Deaths Before, During, After More than half of pregnancy-related maternal deaths occur after delivery Percentage of Maternal Deaths Source: Creanga, A. A., Syverson, C., Seed, K., & Callaghan. W. M. (2017). Pregnancy -Related Mortality in the United States, 2011-2013. https://www.ncbi.nlm.nih.gov/pubmed/28697109
Fragmentation of Care • 50% of all hospitals in US provide care for three or fewer deliveries a day • Team training for readiness to manage preventable morbidity (i.e. limited blood supply) • Tighten the partnership with health centers (clinics), hospital and all obstetrical care providers: obstetricians, family physicians, nurse practitioners, midwives) • telemedicine • Shortage and maldistribution of obstetricians in the US particularly in rural communities • Specialty and subspecialty consultation
Rural vs Urban Care and Maternal Morbidity • Lisonkova et al. CMAJ 2016 • Results • British Columbia, Canada comparing mortality and severe morbidity • death and severe maternal morbidity ( OR-1.15, Ci 1.03-1.28) in rural vs urban • Rural had Higher rate of eclampsia (OR-2.70, Ci 1.79-4.08), embolism (OR- 2.16, CI 1.14-4.07), uterine rupture (OR-1.96, CI 1.42-2.72) than urban women • Infants in rural more likely to have severe neonatal morbidity (OR- 1.14, CI 1.10-1.19 • Conclusions • Providers in rural areas need to be aware of potential morbidities and mortality risk.
Understanding R Raci cial D Disparities: The B Big Pi Pict cture Source: Elisabeth Howell, MD, MPP. Reduction of Peripartum Disparities Bundle. 2017.
Maternal M Mortality ty • Maternal Mortality Review • Preventing Maternal Death Act/ Maternal Health Accountability Act bipartisan legislation December 2018. • Provides financial support and infrastructure for state-based maternal mortality review committees to be established and/or strengthened existing multidisciplinary MMRC.
• In an analysis of 23,692 women with Medicaid, predictors of not attending a postpartum visit included: • Black race • Alcohol or drug use • Mental health disorder other than depression Health Equity • Living in a neighborhood where a high proportion of individuals >25 do not have a high school diploma • Ensuring ALL women are engaged in the support they need following birth is an essential step in achieving health equity Bennett et al (2014) http://www.ncbi.nlm.nih.gov/pubmed/24474651
Teen Birth Sex Education Page 31
Teen Birth by Race
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