Disparities in Severe Maternal Morbidity and Mortality: How Did We - PowerPoint PPT Presentation

Elizabeth Howell Disparities in Severe Maternal Morbidity and Mortality: How Did We Get Here and Where Presenter Disclosures Do We Go From Here Elizabeth Howell MD, MPP Elizabeth Howell, MD, MPP Director, Blavatnik Family Women’s Health Research Institute Professor & Vice Chair of Research Obstetrics, Gynecology, and Reproductive Science I have no personal financial relationships with Icahn School of Medicine at Mount Sinai commercial interests relevant to this presentation 1 2 Overview • Racial/ethnic disparities in maternal mortality and severe maternal morbidity • The role of preconception, antenatal, delivery, and postpartum care in disparities • Research on quality and disparities in severe maternal morbidity in US and NYC Hospitals • Levers to Reduce Disparities Erica – Alliance for Innovation on Maternal Health Garner 3 4

Elizabeth Howell United States Pregnancy-related Mortality by Disparities in Maternal Mortality Race, Ethnicity, Nativity 2000-2006 • Minorities represent half of all US births and 45 racial/ethnic minorities suffer higher maternal 39.9 US Born 40 mortality rates Deaths/100,00 live births Foreign Born 34.1 35 • Black women 3 to 4 times more likely to die than 30 25 white women – largest disparity among 20 population perinatal health measures 15 12.3 11.7 10.9 10.3 10.3 • Native Americans, some Asians, some Latinas 8.4 10 also have elevated rates 5 0 White Black Hispanic Asian/ Pacific CDC Pregnancy Mortality Surveillance System at: Islander https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html Creanga, Obstet Gynecol. 2012 Aug;120(2 Pt 1):261-8. 5 6 CDC US Pregnancy-related Mortality by Race 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. Creanga. J of Women’s Hlth; 2014 Jan;23(1):3-9. 7 8

Elizabeth Howell 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). New York City Department of Health and Mental Hygiene (2015). Pregnancy Associated Mortality in New York City, 2006-2010. Pregnancy Associated Mortality in New York City, 2006-2010. 9 10 Leading Causes of Maternal Deaths in New York City, 2006-2010 30 27.3 Percent of Maternal Deaths 25 18.7 20 13.7 15 12.9 10 5 0 Hemorrhage Embolism Pregnancy- Cardiovascular induced hypertension New York City Department of Health and Mental Hygiene (2015). New York City Department of Health and Mental Hygiene (2015). Pregnancy Associated Pregnancy Associated Mortality in New York City, 2006-2010. 11 12 Mortality in New York City, 2006-2010.

Elizabeth Howell 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. 13 14 Severe Maternal Morbidity Rates in New York In New York City, a black woman with a college City degree is nearly three times more likely than a white woman with a high school degree to develop a severe maternal morbidity during her delivery hospitalization. 94% A. a. True B. b. False 6% Howell Am J Obstet Gynecol. 2016 Aug;215(2):143-52; Howell. Obstet Gynecol. e e s u l r a 2017 Feb;129(2):285-294. T F . a b . 15 16

Elizabeth Howell New York City Department of Health and Mental Hygiene (2016). New York City Department of Health and Mental Hygiene (2016). Severe Maternal Morbidity in New York City, 2008–2012. New York, NY. Severe Maternal Morbidity in New York City, 2008–2012. New York, NY. 17 18 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, insurance, Mortality marital status, employment, language, literacy - Knowledge, beliefs, health Preconception behaviors Care Pregnancy complications - Psychosocial: stress, self- How Did We Get Here? Race/ Ethnicity efficacy, social support Outcomes Community/ Neighborhood Severe Postpartum Antenatal - Community, social network Maternal Care Care - Neighborhood: crime, poverty, Morbidity built environment, housing & Mortality Provider Factors - Knowledge, experience, Delivery & Hospital implicit bias, cultural Care competence, communi- cation System Factors - Access to high quality care, Howell EA. Clin Obstet Gynecol. 2018 Jan transportation, structural 16. [Epub] 19 20 racism, policy

Elizabeth Howell Preconception, Postpartum Care, and Antenatal Care and Disparities Disparities • No or few antenatal visits associated with SMM and • Drivers of SMM and mortality - obesity, HTN, mortality diabetes - higher among black and Latina women • Black and Latina vs. white women are: • Unintended pregnancy more common among black – more likely to receive 0-5 prenatal care visits and Latina women and linked with worse perinatal – less likely to have early prenatal care outcomes • Delay of prenatal care associated with experience of racism • Postpartum care important for long term health but • Quarter of mothers perceive discrimination during rates are low birth hospitalization Finer LB. NEJM. 2016;374:843-852 ; De Bocanegra HT. Am J Obstet Gynecol. Harper MA. Ann Epidemiol. 2004:14:274-279. Howell Am J Obstet Gynecol. 2016 2017;217-47.e1-47.e7. Aug;215(2):143-52; Howell. Obstet Gynecol. 2017;129:285-294; Slaughter-Acey JC. Womens Health Issues. 2013;23;e381-e387. 21 22 Research on Delivery Hospital and US Disparities Hospital Quality and Disparities • In US, 75% of all black deliveries occur in a • Nearly one-half of severe events / maternal quarter of all hospitals vs. 18% of white deliveries deaths preventable • Hospitals that disproportionately care for black • Hospital quality important contributing factor deliveries • Site of care receiving increasing attention as – have higher risk adjusted SMM rates for both blacks mechanism for disparities and whites – perform worse than other hospitals on delivery-related • Growing body of research suggests racial/ethnic indicators women deliver in lower quality hospitals Howell. Am J Obstet Gynecol. 2016 Jan;214(1):122.e1-e9; Creanga AJOG 2014 Geller. Womens Health Issues 2006 Jul-Aug;16(4):176-88; Howell. Am J Obstet Dec;211(6):647.e1-16. Gynecol. 2016 Jan;214(1):122.e1-e9. Howell Obstet & Gynecol 2017; Creanga 23 24 AJOG 2014;

Elizabeth Howell Distribution of Black and White Deliveries at Distribution of Black and White Deliveries at Black-serving Hospitals in US Black-serving Hospitals in US Cumulative Percentage of Deliveries Cumulative Percentage of Deliveries 100% 100% Much higher rates of maternal 82% 82% morbidity for black and white moms 80% 80% 60% 60% 50% 50% 40% 40% 26% 26% 24% 24% 16% 16% 20% 20% 2% 2% 0% 0% High Medium Low High Medium Low (N=279) (N=1106) (N=4102) (N=279) (N=1106) (N=4102) Black White Black White Howell. Am J Obstet Gynecol. 2016 Jan;214(1):122.e1-e9 Howell. Am J Obstet Gynecol. 2016 Jan;214(1):122.e1-e9 25 26 Delivery Hospital and NYC Disparities* Phase 1 Methods • Phase 1 - Examine risk-adjusted severe maternal • Vital Statistics linked with SPARCS for all New York morbidity and extent to which hospital quality City deliveries (2011-2013) contributes to racial / ethnic disparities in SMM • CDC algorithm to identify severe morbidity • Phase 2 – Hospital qualitative interviews to examine safety and culture, quality improvement, and other • Mixed-effects logistic regression to calculate risk- factors associated with high quality care standardized severe maternal morbidity rates • Phase 3 – Focus groups with moms (SSMMR) for each hospital • Phase 4 – Dissemination; promotion of best practices • Ranked hospitals based on SSMMR • Assessed black-white differences and Hispanic- white differences in delivery location *Funded by NIH; Howell Am J Obstet Gynecol. 2016 Aug;215(2):143-52; Howell. Obstet Gynecol. 2017 Feb;129(2):285-294. 27 28