Disparities In Maternal Morbidity Research Articles

Factors Associated with Maternal Morbidity among Black Women in the United States.

Non-Hispanic Black people (NHBP) have a three-fold higher rate of maternal mortality compared to other racial groups. Racial disparities in maternal morbidity are well-described; however, there are substantial differences in cultural, economic, and social determinants of health among racial groups. We thus sought to study the at-risk, non-Hispanic Black population as its own cohort to identify factors most associated with severe maternal morbidity (SMM). This is a population-based retrospective case-control study of all live births in the United States between 2017 and 2019 using birth records obtained from the National Center for Health Statistics. The primary outcome for this study was to determine demographic, social, medical, and obstetric factors associated with maternal morbidity among NHBP who did and did not experience an SMM event. Multivariable logistic regression was used to estimate the adjusted odds ratio between each individual factor and the outcome of SMM among NHBP. Of the 1,624,744 NHBP who delivered between 2017 and 2019, 1.1% experienced an SMM event defined as a composite of blood product transfusion, eclamptic seizure, intensive care unit admission, unplanned hysterectomy, and uterine rupture. The rates of these individual SMM events per 10,000 deliveries were 50, 40, 20, 5, and 4 among NHBP, respectively. Among NHBP, factors associated in multivariable regression analysis with SMM in order of strength of association included cesarean delivery, earlier gestational age at delivery, preeclampsia, induction of labor, chronic hypertension, prior preterm birth, lower educational attainment, multifetal gestation, advanced maternal age, pregestational diabetes, and cigarette smoking. The population attributable fraction for cesarean delivery, preterm birth, and pregnancy-induced hypertensive disease for the outcome of SMM were 0.46, 0.23, and 0.07, respectively. The three factors most associated with SMM among NHBP are potentially avoidable or modifiable by aggressive screening, prevention, and treatment of preeclampsia and preterm birth as well as reducing cesarean rates in this population. · The rate of SMM in NHBP may be modifiable.. · NHBP have a three-fold higher rate of maternal mortality.. · Preeclampsia, preterm birth, and cesarean sections are most associated with maternal morbidity..

Readiness to Implement a Doula–Hospital Partnership Program

ObjectiveTo assess obstetric clinicians’ and leaders’ baseline knowledge, attitudes, and experience with doulas and their readiness to implement a novel doula–hospital partnership program. DesignSurvey of obstetric clinicians and leaders before implementation of the doula program. Setting/Local ProblemAcademic medical center in Western Massachusetts that was preparing to pilot a doula–hospital partnership program with Black doulas for Black women to address racial disparities in maternal morbidity and mortality. ParticipantsObstetric clinicians and leaders (N = 48). Intervention/MeasurementsWe used established questions from the Organizational Readiness for Implementing Change (ORIC) scale and original questions to assess participants’ knowledge, attitudes, and experiences with doulas and their readiness to implement the planned doula program. We distributed the questionnaire to 103 potential respondents. We conducted descriptive and bivariate analyses and analyzed open-ended responses using content analysis. ResultsForty-eight participants responded to the survey. Of those who provided intrapartum care (n = 45), all were familiar with doula roles. Respondents who reported having experience working with a doula, 47.3% (n = 18/38) had at least one prior negative experience with a doula and 76.3% (n = 29/38) reported positive experiences with doulas. However, there was a mean score of 12.62 on the attitude toward doulas (scale range: 3-15). The mean score on the ORIC change commitment subscale was 20.65 (range: 15-25) and on the ORIC change efficacy subscale, mean score was 29.31 (range: 19-35). Results did not differ by participants characteristics. ConclusionOur findings suggested strong support for and readiness to implement the doula–hospital partnership program.

Reply: The Risk Factor for Maternal Morbidity is Racism, Not Race.

We agree with Drs. Rollin, Krishnamurthy and Weerahandi1 that race is a social construct and has been used in medicine and research to explain differences in outcomes that are more appropriately attributed to inequities in health care and social determinants of health due to systemic racism. In our paper we explicitly state in the discussion that our findings of increased maternal morbidity for individuals who identify as non-Hispanic Black reflect "implicit bias, structural racism, and quality of care in obstetrics". We appreciate the authors' point that references to race earlier and elsewhere in the paper could have been replaced by 'exposure to racism'. Our approach was to report results based on the data directly measured by us (self-reported race) and introduce in the Discussion the most likely underlying reason (racism) for the effect of race in the analysis. We welcome this discussion about better approaches to address this critical concern in research publications. Lastly, we understand the concerns raised about Table 1 in the original paper where "Other" and "Asian" reported races were combined with "White." This collapsing of racial categories was performed for analysis due to insufficient sample size of patients self-reporting "Other" or "Asian" as their race, which precluded independent analysis. We appreciate that combining those groups with White participants into a single reference category could potentially bias the results towards the null, as individuals in these racial groups also experience worse maternal health outcomes compared with White birthing persons.4 We agree that exposure to racism is related to poorer obstetric outcomes and future efforts need to focus on preventing structural racism in order to reduce the observed disparities in maternal morbidity and mortality by race.

Listen to the Whispers before They Become Screams: Addressing Black Maternal Morbidity and Mortality in the United States.

Black women in the United States (U.S.) disproportionately experience adverse pregnancy outcomes, including maternal mortality, compared to women of other racial and ethnic groups. Historical legacies of institutionalized racism and bias in medicine compound this problem. The disproportionate impact of COVID-19 on communities of color may further worsen existing racial disparities in maternal morbidity and mortality. This paper discusses structural and social determinants of racial disparities with a focus on the Black maternal mortality crisis in the United States. We explore how structural racism contributes to a greater risk of adverse obstetric outcomes among Black women in the U.S. We also propose public health, healthcare systems, and community-engaged approaches to decrease racial disparities in maternal morbidity and mortality.

Rural-Urban Disparities in Adverse Maternal Outcomes in the United States, 2016-2019.

Objectives. To describe differences in maternal admissions to the intensive care unit (ICU) and mortality in rural versus urban areas in the United States. Methods. We performed a nationwide analysis and calculated age-standardized rates and rate ratios (RRs) of maternal ICU admission and mortality per 100 000 live births between 2016 and 2019 in rural versus urban areas. Results. From 2016 to 2019, there was no significant increase in age-standardized rates of maternal ICU admissions in rural (170.6-192.3) or urban (161.7-172.4) areas, with a significantly higher rate, albeit a relatively small difference, in rural versus urban areas (2019 RR = 1.14; 95% confidence interval [CI] = 1.04, 1.20). Maternal mortality increased in both rural (66.9-81.7 deaths per 100 000 live births) and urban (38.1-42.3) areas and was nearly 2 times higher in rural areas (2019 RR = 1.93; 95% CI = 1.71, 2.17). Conclusions. Pregnant individuals in rural areas are at higher risk for ICU admission and mortality than are their urban counterparts. Significant increases in maternal mortality occurred in rural and urban areas. Public Health Implications. Public health efforts need to focus on resource-limited rural areas to mitigate geographic disparities in maternal morbidity and mortality. (Am J Public Health. 2023;113(2): 224-227.https://doi.org/10.2105/AJPH.2022.307134).

Obstetric experiences of young black mothers: An intersectional perspective

BackgroundIn Chicago, maternal morbidity and mortality is six times more likely among Black birthing people than white, despite policy initiatives to promote maternal health equity. Disparities in maternal morbidity and mortality reflect experiences of structural inequities – including limited quality obstetric care, implicit bias, and racism resulting patient mistrust in the health care system, inadequate social support, and financial insecurity. Although there is published literature on Black women's experiences with obstetric care, including experiences with individual and structural racism, little is known about the intersection of age and race and experiences with health care. The purpose of this study was to explore the maternal health and pregnancy experiences of young Black women utilizing an intersectional theoretical lens. MethodsIn this study, we conducted two focus groups in a sample of 11 young Black pregnant people. We conducted a thematic analysis to identify codes, themes, and subthemes of the data. ResultsWe developed two overarching themes: obstetric racism and obstetric resistance. To elucidate how obstetric racism framed our participants’ healthcare experiences, we identified sub-themes: intersectional identities as young Black women, medical mistrust, and pregnancy trauma. The second major theme describes ways in which participants protected themselves against obstetric racism to engender positive health experiences. These methods of resistance included identifying advocates and relying on trusted providers. ConclusionsThe current standard of obstetric care in the US is suboptimal due to individual and structural racism. This study provides unique data on the experiences with health care for young, Black pregnant individuals and delivers valuable insight into how individual and structural racism impacts obstetric care for young Black women.

Addressing Implicit Bias in the Women’s Health Department

Significant racial and ethnic disparities in maternal morbidity and mortality exist in the United States. Black women are three to four times more likely to die of pregnancy-related complications compared with White women. Health care providers’ implicit bias can contribute directly to inequality and may adversely influence these outcomes.

Perinatal quality collaboratives and birth equity.

The purpose of this review is to discuss how state perinatal quality collaboratives are addressing birth equity to reduce disparities in maternal morbidity and mortality. Perinatal quality collaboratives are adopting core practices to advance birth equity, reduce disparities and confront racism and bias in obstetric care including securing leadership commitments to equity, providing education on the causes of inequities and mitigation strategies, collecting accurate race/ethnicity data, addressing social determinants of health, and integrating patient and community knowledge, experiences, and narratives in the quality improvement work. Inequities in maternal morbidity and mortality particularly affecting Black birthing people are driven by racism, inequities in the social determinants of health, and variations in care practices and quality. Perinatal quality collaboratives are an important resource for driving improvement changes to mitigate these factors and improve outcomes. Mason CL, Collier CH, Penny SC. Perinatal Quality Collaboratives and Birth Equity. Produced by CLMB Productions for use in this publication. January 10, 2022, http://links.lww.com/COAN/A86.

Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity

The objective of this study was to evaluate the impact of quality improvement (QI) and patient safety initiatives and data disaggregation on racial disparities in severe maternal morbidity from hemorrhage...

A Community Collaborative for the Exploration of Local Factors Affecting Black Mothers' Experiences with Perinatal Care.

ObjectivesBlack women face disparities in maternal morbidity and mortality when compared to White women. Multiple factors contribute to these disparities. This study examines the perspectives of Black women who have given birth in the last 5 years, to understand their pregnancy and birth experiences as a means of ascertaining factors that may be contributing to these disparities.MethodsThe Consortium to End Black Maternal Mortality was established as a collaborative table of cross-sector stakeholders and Black mothers to effectively conduct community-based participatory research focused on Black maternal health. Between January and March 2020, Black mothers who had given birth in the last 5 years facilitated Listening Sessions (LS) with other Black mothers in Rochester, NY. Participants reported on details of their pregnancy and delivery, including interaction with providers, personal relationships and their individual experience. The qualitative data captured during these sessions were coded to draw out key themes which were validated with LS participants and the Consortium.ResultsThe key themes that emerged clustered into four groups, including: (1) Mother-Provider Communication; (2) Social Support; (3) Systemic factors and (4) Maternal Emotional & Mental Health. Mother-provider communication was the most salient factor affecting the maternal experience and was found to be influenced primarily by maternal health literacy and provider discriminatory attitudes and behaviors.Conclusions for PracticeAs a result of the Listening Sessions conducted with Black women, we identified mother-provider communication as the most important factor influencing the maternal experience.

Color lines: Disparities in pharmacy treatment, education, and practice

Color lines: Disparities in pharmacy treatment, education, and practice

Factors associated with maternal morbidity among non-Hispanic Black women in the United States

Non-Hispanic Black women have a 3-fold higher rate of maternal mortality compared to other racial groups. Racial disparities in maternal morbidity are well described; however, there are substantial cultural, economic, and social determinants of health differences among racial groups. We thus sought to study this, at-risk, Black population as its own cohort to identify factors most associated with severe maternal morbidity (SMM).

Evaluating the OB-CMI as a Predictive Tool for Severe Maternal Morbidity by Race and Ethnicity

Racial and ethnic disparities in maternal morbidity remain a significant challenge. The purpose of this study is to evaluate the performance of the Obstetric Co-Morbidity Index (OB-CMI), a validated tool that predicts severe maternal morbidity (SMM) in clinical settings, by race and ethnicity.

Racial and Ethnic Disparities in Death Associated With Severe Maternal Morbidity in the United States: Failure to Rescue

(Obstet Gynecol. 2021;137:791–800) Where women deliver has significant consequences due to racial and ethnic disparities in maternal morbidity within the United States. Rates of severe maternal morbidity and failure to rescue are strong indicators for hospital performance, which have been reportedly higher in Black and Hispanic women than in White women. This study aims to identify historical trends and enumerate failure-to-rescue racial and ethnic disparities during delivery in association with severe maternal morbidity.

Cardiovascular Disease in Pregnancy.

Cardiovascular disease remains a major contributor to rising maternal morbidity and mortality. Both the pregnant woman and fetus are exposed to many potential complications as a result of the physiologic changes of pregnancy. These changes can exacerbate existing cardiac disease, as well as lead to the development of de novo issues during gestation, delivery, and the postnatal period. For women with preexisting cardiac disease, including congenital malformations, valvular disease, coronary artery disease, and aortopathies, it is crucial that they receive multidisciplinary evaluation, counseling, and optimization before conception, as well as close monitoring and medication management during pregnancy. Close monitoring is also essential for patients who develop cardiovascular complications such as preeclampsia, cardiomyopathy, congestive heart failure, coronary events, and arrhythmias during pregnancy. In addition, concerning disparities in maternal morbidity and mortality exist across many dimensions, in part because of the lack of uniformity of care in different treatment settings. Establishment of multidisciplinary cardio-obstetric teams including representatives from cardiology, anesthesia, obstetrics, maternal-fetal medicine, and specialized nursing has proven instrumental to delivering evidence-based and equitable care to high-risk patients. Multidisciplinary teams should work to guide these patients through the preconception, antepartum, delivery, and postpartum phases to ensure appropriate care for weeks to years after pregnancy.

Obstetrical unit closures and racial and ethnic differences in severe maternal morbidity in the state of New Jersey

In the United States, racial disparities in maternal morbidity and mortality are pronounced and persistent. Although the maternal mortality ratio and the severe maternal morbidity rates have increased over the past 30 years, the number of obstetrical units in the country has simultaneously diminished. Black women are 3 times more likely to die during childbirth than White women and twice as likely to suffer severe maternal morbidity (or a near miss). Between 2003 and 2013, 366 (10%) obstetrical units closed, and rural obstetrical unit closures were more likely in the Black communities. The state of New Jersey has the highest Black maternal mortality rate (131.8/100,000 live births) of all states reporting these data. Very few studies have examined the role that urban obstetrical unit closures play in racial and ethnic disparities in maternal health outcomes. To analyze racial differences in severe maternal morbidity in New Jersey hospitals among women experiencing the loss of their nearest obstetrical unit during the years 2006-2015. This study used data on all births in New Jersey hospitals (2006-2015) by women living in ZIP code tabulation areas that lost their nearest obstetrical unit during that period. Severe maternal morbidity was measured using a composite variable for severe illness during hospitalizations (eg, acute heart failure, acute renal disease, disseminated intravascular coagulation, sepsis) identified using the International Classification of Diseases, Ninth Revision. Logistic regression models were used to analyze the associations between race and ethnicity on the individual likelihood of severe maternal morbidity, adjusting for annual trends, individual socioeconomic characteristics, age, preexisting conditions, and delivery hospital characteristics (ie, percentage of Black patients >25% [Black-serving hospital] and percentage of Medicaid discharges in the delivery obstetrical unit). There were 227,412 delivery hospitalizations among women who lived in the 124 New Jersey ZIP code tabulation areas that lost the nearest obstetrical unit from 2006 to 2015. Black women had the highest severe maternal morbidity rates, increasing from 1.2% in 2006 to 2.3% in 2015. The Black-White gap remained similar in magnitude over the period, as White women's severe maternal morbidity rates increased from 0.7% to 1.4%. However, for Hispanic women, the severe maternal morbidity increased dramatically from 0.7% in 2006 to 2.4% in 2013, followed by a decreasing trend during 2013-2015. When adjusting for individual factors, the odds of severe maternal morbidity among all women was greater if they delivered after the loss of the nearest obstetrical unit (adjusted odds ratio, 1.55; 95% confidence interval, 1.30-1.86). Hispanic women experienced the greatest increase in severe maternal morbidity, regardless of whether they delivered before or after the closure of their nearest obstetrical unit. For all women, delivering in a Black-serving obstetrical unit was associated with a greater likelihood of individual severe maternal morbidity (adjusted odds ratio, 1.36; 95% confidence interval, 1.19-1.56). Racial and ethnic disparities in severe maternal morbidity persist and might be exacerbated by nearby obstetrical unit closures. In New Jersey ZIP codes with obstetrical unit loss, the Hispanic-White gap in the severe maternal morbidity widened substantially, and the rates were also higher among women who delivered in Black-serving hospitals. Policymakers should take steps to prevent obstetrical unit closures and to ensure that the resources available at Black-serving obstetrical units are at least on par with those of other institutions.

Reply by Authors.

No AccessJournal of UrologyAdult Urology1 Oct 2021Reply by Authorsis a reply to letterEditorial Comment Mohammad I. Khojah, Ahmad M. Badeghiesh, Sara Ismail, Haitham A. Baghlaf, Noor Almamlouk, and Michael H. Dahan Mohammad I. KhojahMohammad I. Khojah Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada More articles by this author , Ahmad M. BadeghieshAhmad M. Badeghiesh Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada More articles by this author , Sara IsmailSara Ismail Faculty of Medicine, McGill University, Montréal, Quebec, Canada More articles by this author , Haitham A. BaghlafHaitham A. Baghlaf Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada More articles by this author , Noor AlmamloukNoor Almamlouk Faculty of Science, McGill University, Montréal, Quebec, Canada More articles by this author , and Michael H. DahanMichael H. Dahan *Correspondence: McGill University Health Center, 1001 Decarie Blvd., Montreal, Quebec H4A 3J1 telephone: + 1 (514) 843-1650; FAX: +1 (514) 843-1496; E-mail Address: [email protected] http://orcid.org/0000-0002-8121-7708 MUHC Reproductive Centre, McGill University, Montréal, Quebec, Canada More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001875.02AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Reply by Authors." The Journal of Urology, 206(4), p. 985 Reference 1. : Racial and ethnic disparities in maternal morbidity and obstetric care. Obstet Gynecol 2015; 125: 1460. Google Scholar © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of UrologyJul 27, 2021, 12:00:00 AMEditorial Comment Volume 206Issue 4October 2021Page: 985-985 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mohammad I. Khojah Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada More articles by this author Ahmad M. Badeghiesh Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada More articles by this author Sara Ismail Faculty of Medicine, McGill University, Montréal, Quebec, Canada More articles by this author Haitham A. Baghlaf Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada More articles by this author Noor Almamlouk Faculty of Science, McGill University, Montréal, Quebec, Canada More articles by this author Michael H. Dahan MUHC Reproductive Centre, McGill University, Montréal, Quebec, Canada *Correspondence: McGill University Health Center, 1001 Decarie Blvd., Montreal, Quebec H4A 3J1 telephone: + 1 (514) 843-1650; FAX: +1 (514) 843-1496; E-mail Address: [email protected] More articles by this author Expand All Advertisement PDF DownloadLoading ...

Women and babies are dying from inertia: a collaborative framework for obstetrical drug development is urgently needed

Obstetrical complications, often referred to as the "great obstetrical syndromes," are among the most common global causes of mortality and morbidity in young women and their infants. However, treatments for these syndromes are underdeveloped compared with other fields of medicine and are urgently needed. This current paucity of treatments for obstetrical complications is a reflection of the challenges of drug development in pregnancy. The appetite of pharmaceutical companies to invest in research for obstetrical syndromes is generally reduced by concerns for maternal, fetal, and infant safety, poor definition, and high-risk regulatory paths toward product approval. Notably, drug candidates require large investments for development with an unguaranteed return on investment. Furthermore, the discovery of promising drug candidates is hampered by a poor understanding of the pathophysiology of obstetrical syndromes and their uniqueness to human pregnancies. This limits translational extrapolation and de-risking strategies in preclinical studies, as available for other medical areas, compounded with limited fetal safety monitoring to capture early prenatal adverse reactions. In addition, the ethical review committees are reluctant to approve the inclusion of pregnant women in trials, and in the absence of regulatory guidance in obstetrics, clinical development programs are subject to unpredictable regulatory paths. To develop effective and safe drugs for pregnancy complications, substantial commitment, and investment in research for innovative therapies are needed in parallel with the creation of an enabling ethical, legislative, and guidance framework. Solutions are proposed to enable stakeholders to work with a common set of expectations to facilitate progress in this medical discipline. Addressing this significant unmet need to advance maternal and possibly perinatal health requires the involvement of all stakeholders and specifically patients, couples, and clinicians facing pregnancy complications in the dearth of appropriate therapies. This paper focused on the key pharmaceutical research and development challenges to achieve effective and safe treatments for obstetrical syndromes.

Reduction in Racial Disparities in Severe Maternal Morbidity From Hemorrhage in a Large-scale Quality Improvement Collaborative

(Am J Obstet Gynecol. 2020;223:123.e1–14) Racial and ethnic disparities in maternal morbidity and mortality continue to persist in the United States. Maternal death is 3-4 times more likely in black women than in white women, and the risk for severe maternal morbidity (SMM) is 2 times greater among black women than white women. Many of these cases are believed to be preventable by addressing the quality of care. Quality improvement (QI) collaboratives have been put forth as one way to reduce these disparities, but little is known about their effectiveness on racial/ethnic disparities in maternal outcomes. The aim of this study was to investigate whether a QI collaborative could narrow the difference in the rates of SMM from hemorrhage between black and white pregnant women.

Racial Disparities in Maternal Critical Care: Are There Racial Differences in Level of Care?

Obstetric care in the US is complicated by marked racial and ethnic disparities in maternal obstetric outcomes, including severe morbidity and mortality, which are not explained by underlying differences in patient characteristics. Understanding differences in care delivery related to clinical acuity across different racial groups may help elucidate the source of these disparities. This study examined the association of maternal race with utilization of critical care interventions. This is a retrospective cohort study conducted as a secondary analysis of a large, multicenter observational study of women undergoing cesarean delivery. All women with a known delivery date were included. The primary outcome measure, a composite of critical care interventions (CCI) at delivery or postpartum that included mechanical ventilation, central and arterial line placement, and intensive care unit (ICU) admission were compared by racial/ethnic group-non-Hispanic white, non-Hispanic black, Hispanic, Asian, and Native American. We evaluated differences in utilization of critical care with a multivariable regression model accounting for selected characteristics present at admission for delivery, including maternal age, BMI, co-morbidities, parity, and plurality. Maternal mortality was also evaluated as a secondary outcome and the frequency of CCI by significant maternal co-morbidity, specifically heart disease, renal disease, and chronic hypertension was assessed to ascertain the level of care provided to women of different race/ethnicity with specific baseline co-morbidities. 73,096 of 73,257 women in the parent trial met inclusion criteria, of whom 505 (0.7%) received a CCI and 3337 (4.6%) had a significant medical co-morbidity (1.2% heart disease, 0.8% renal disease, 2.5% chronic hypertension). The mortality rate was significantly higher among non-Hispanic black women, compared to non-Hispanic white and Hispanic women. In the adjusted model, there was no significant association between CCI and race/ethnicity. This study suggests that differences in maternal morbidity by race may be accounted for by differential escalation to higher intensity care. Further investigation into processes for care intensification may continue to clarify sources of racial and ethnic disparities in maternal morbidity and potential for improvement.