Disparities in Severe Maternal Morbidity and Mortality ...

Elizabeth Howell

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Disparities in Severe Maternal Morbidity and Mortality: Where Do We Go From

Here?

Elizabeth Howell MD, MPP Director, Blavatnik Family Women’s Health Research Institute

Professor & Vice Chair of ResearchObstetrics, Gynecology, and Reproductive Science

Icahn School of Medicine at Mount Sinai

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Presenter Disclosures

I have no personal financial relationships with commercial interests relevant to this presentation

Elizabeth Howell, MD, MPP

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Objectives

• Describe racial and ethnic disparities in severe maternal mortality and morbidity

• Understand how delivery care may impact disparities in severe maternal morbidity and mortality

• Describe steps that institutions can take to address racial and ethnic disparities in severe maternal morbidity and mortality

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Elizabeth Howell

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Maternal Healthcare Crisis

New York Times

ProPublica and NPR. Accessed 9/28/18. https://www.npr.org/2017/05/12/528098789/u-s-has-the-worst-rate-of-maternal-deaths-in-the-developed-worldBased on data from "Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015," The Lancet. Only data for 1990, 2000 and 2015 was made available in the journal. Source: The Lancet Credit: Rob Weychert/ProPublica

US Maternal Mortality Rises while it Declines Elsewhere

Disparities in Maternal Mortality

• Minorities represent half of 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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Elizabeth Howell

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

10.3

39.9

10.3 10.98.4

34.1

12.3 11.7

0

5

10

15

20

25

30

35

40

45

White Black Hispanic Asian/ PacificIslander

US Born

Not US Born

Dea

ths/

100,

00 li

ve b

irths

Creanga, Obstet Gynecol. 2012 Aug;120(2 Pt 1):261-8. 7

Pregnancy-Related Mortality Ratios by Race-Ethnicity, 2011-2013

43.5

14.4 12.7 11.0

0

5

10

15

20

25

30

35

40

45

50

Non-HispanicBlack

Non-HispanicWhite

Hispanic Other Race-Ethnicities

Pre

gnan

cy-r

elat

ed m

orta

lity

ratio

per

10

0,00

0 liv

e bi

rths

Creanga Obstet Gynecol. 2017;130(2),366–373.

Creanga. J of Women’s Hlth; 2014 Jan;23(1):3-9.

CDC US Pregnancy-related Mortality by Race

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Elizabeth Howell

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Maternal Mortality (per 100,000)

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Moaddab.A.Health Care Disparity and State-Specific Pregnancy-Related Mortality in the United States, 2005-2014. ObstetGynecol 2018;131:707–12.

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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New York City Department of Health and Mental Hygiene (2015).Pregnancy Associated Mortality in New York City, 2006-2010. 12

Elizabeth Howell

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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 maternal 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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Elizabeth Howell

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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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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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How Did We Get Here?

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Elizabeth Howell

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Patient Factors - Socio-demographics: age,

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

- Knowledge, beliefs, healthbehaviors

- 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

Rac

e/ E

thn

icit

y

Community/ Neighborhood- Community, social network- Neighborhood: crime,

poverty, built environment, housing

He

alt

h s

tatu

s:

co

mo

rbid

itie

s (

e.g

. H

TN

, D

M,

ob

es

ity,

de

pre

ss

ion

);

Pre

gn

an

cy

co

mp

lica

tio

ns

Provider Factors- Knowledge, experience,

implicit bias, cultural competence, communi-cation

System Factors- Access to high quality care,

transportation, structural racism, policy

Howell EA. Clin Obstet Gynecol. 2018 Jun;61(2):387-399

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Patient Factors - Socio-demographics: age,

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

- Knowledge, beliefs, healthbehaviors

- 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

Rac

e/ E

thn

icit

y

Community/ Neighborhood- Community, social network- Neighborhood: crime,

poverty, built environment, housing

He

alt

h s

tatu

s:

co

mo

rbid

itie

s (

e.g

. H

TN

, D

M,

ob

es

ity,

de

pre

ss

ion

);

Pre

gn

an

cy

co

mp

lica

tio

ns

Provider Factors- Knowledge, experience,

implicit bias, cultural competence, communi-cation

System Factors- Access to high quality care,

transportation, structural racism, policy

Howell EA. Clin Obstet Gynecol. 2018 Jun;61(2):387-399

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Hospital Quality and Disparities

• Sixty percent 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

Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal mortality review committees. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs. Howell. Am J Obstet Gynecol. 2016 Jan;214(1):122.e1-e9. Creanga AJOG 2014 21

Elizabeth Howell

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Research on Delivery Hospital and US Disparities

• In US, 75% of all black women deliver in a quarter of all hospitals vs. 18% of white women

• Hospitals that disproportionately care for black women– 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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Methods

• Nationwide Inpatient Sample (2010 – 2011)

• Identified severe maternal morbidity (SMM)

• Ranked hospitals by proportion of black women who delivered in the hospital:– High (top 5%) - Medium (5-25%)

– Low (remainder)

• Analyzed risks of SMM for black and white women by hospital category using logistic regression adjusting for patient comorbidities, hospital factors, and patient clustering

Distribution of Black and White Deliveries at Hospitals in US

24%

50%

26%

2%

16%

82%

0%

20%

40%

60%

80%

100%

High Medium LowCu

mu

lati

ve P

erce

nta

ge

of

Del

iver

ies

Black White(N=279) (N=1106) (N=4102)

Howell. Am J Obstet Gynecol. 2016 Jan;214(1):122.e1-e924

Elizabeth Howell

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Distribution of Black and White Deliveries at Hospitals in US

24%

50%

26%

2%

16%

82%

0%

20%

40%

60%

80%

100%

High Medium LowCu

mu

lati

ve P

erce

nta

ge

of

Del

iver

ies

Black White(N=279) (N=1106) (N=4102)

Much higher rates of severe maternal morbidity for black and white moms

Howell. Am J Obstet Gynecol. 2016 Jan;214(1):122.e1-e925

Implications

• Differential access to higher quality hospitals may partially explain excess morbidity among black women

• Research needed to investigate clinical and hospital factors that contribute to disparities and severe morbidity

• Specific research needed to identify attributes of high performing hospitals

Next Steps in Our ResearchNew York City Hospitals*

• Mixed methods study to investigate hospital quality and disparities in SMM

• Examine hospital risk-adjusted SMM and racial/ethnic distribution of deliveries

• Conduct qualitative interviews to examine safety culture, QI, and other factors

• Conduct focus groups to explore receipt of high quality care

*Funded by NIH #R01MD007651Howell Am J Obstet Gynecol. 2016 Aug;215(2):143-52; Howell. Obstet Gynecol. 2017 Feb;129(2):285-294.

Elizabeth Howell

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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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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 Latina White

Black

Latina

White

Howell Am J Obstet Gynecol. 2016 Aug;215(2):143-52; Howell. Obstet Gynecol. 2017 Feb;129(2):285-294.

0%

1%

2%

3%

4%

5%

6%

7%

Ris

k st

and

ard

ized

m

ater

nal

mo

rbid

ity

(%)

RSSMM

Hospitals ranked from lowest to highest Observed rates: 0.6% to 11.5%; Risk standardized rates: 0.8% to 5.7%

Hospital Rankings

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0%

1%

2%

3%

4%

5%

6%

7%

Ris

k st

and

ard

ized

m

ater

nal

mo

rbid

ity

(%)

RSSMM

Low Morbidity

Medium Morbidity

HighMorbidity

Hospitals ranked from lowest to highest morbidity Observed rates: 0.6% to 11.5%; Risk standardized rates: 0.8% to 5.7%

Hospital Rankings

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Deliveries by Race / Ethnicity 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 /Ethnicity and Risk-standardized Hospital Morbidity


Low Medium High

Black (%) 23 39 37

White (%) 65 17 18

Hispanic (%) 33 38 29


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Elizabeth Howell

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Deliveries by Race / Ethnicity and Risk-standardized Hospital Morbidity


Low Medium High

Black (%) 23 39 37

White (%) 65 17 18

Hispanic (%) 33 38 29


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Thought Experiment

• Differences in hospital of delivery may account for up to:– 48% of the black-white disparity

– 37% of the Hispanic-white disparity

Howell Am J Obstet Gynecol. 2016 Aug;215(2):143-52; Howell. ObstetGynecol. 2017 Feb;129(2):285-294

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

• Delivery location partially explains morbidity disparities

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Elizabeth Howell

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Next Steps

• Currently conducting hospital qualitative interviews

• Focus groups to explore patient barriers to receipt of high quality care

• Dissemination efforts to increase uptake of best practices

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Qualitative Interview Topics• Structural Characteristics (e.g. staffing,

credentialing, capacity, resources, environment)

• Organization Factors (culture, leadership, feedback, communication, promotion of evidence-based practices, progress in QI and disparities reduction)

• L&D (use of evidence-based practices, teamwork, culture, errors, drills)

Types of Interviewees

• Directors of L&D

• Chairs of Ob/Gyn

• Nurse managers for L&D

• Front line nurses

• Chief Medical Officer or designee

• Quality leads in obstetrics

Elizabeth Howell

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Where Do We Go From Here?Levers to Reduce Disparities

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Outcomes Severe

Maternal Morbidity &

Mortality

Preconception Care

Antenatal Care

Delivery & Hospital Care

Postpartum Care

Levers to Reduce Racial and Ethnic Disparities in Severe Maternal Morbidity & Mortality

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Outcomes Severe


Mortality

Preconception Care

Antenatal Care


Postpartum Care


Promote contraceptionOptimize preconception health

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Outcomes Severe


Mortality

Preconception Care

Antenatal Care


Postpartum Care



New models –Centering, Medical Homes, enhanced models for high risk women

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Outcomes Severe


Mortality

Preconception Care

Antenatal Care


Postpartum Care




QI, standardization, bundles, team training, simulations, reviews, protocols, disparities dashboard

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Outcomes Severe


Mortality

Preconception Care

Antenatal Care


Postpartum Care




New models –Patient navigatorsCase management


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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 ProPublicaand 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.” 47

Outcomes Severe


Mortality

Preconception Care

Antenatal Care


Postpartum Care




New models –Patient navigatorsCase management


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Elizabeth Howell

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Slide 49

Friday, November 4, 2016

12:30 p.m. EasternDial 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

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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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Reduction of Peripartum Racial Disparities Patient Safety Bundle Development

Multidisciplinary Team– William Grobman, MD, FACOG

– Elizabeth Howell, MD, MPP, FACOG

– Haywood Brown, MD

– Jessica Brumley, PhD, CNM

– Allison Bryant, MD, MPH

– Aaron Caughey, MD, PhD

– Andria Cornell, MSPH

– Jacqueline Grant, MD, MPH, MPA

– Kimberly Gregory, MD, MPH

– Sue Gullo, RN, BSN, MS

– Pandora Hardtman, CNM

– Jill Mhyre, MD

– Katy Kozhimannil, PhD, MPA

– Jill Mhyre,MD

– Geeta Sehgal, DO

– Paloma Toledo, MD, MPH

– Robyn D’Oria, MA, RNC, APN

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Bundle Development

• 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

• Care fragmentation– Importance throughout reproductive life

• Communication– Patient education (culturally competent)

– Shared decision-making

• Systemic racism– Implicit bias

• Lack of measurement and benchmarking– Disparity dashboard

– Inter-hospital differences 55

Four Domains of Patient Safety Bundles

• Readiness

• Recognition

• Response

• Reporting/Systems Learning

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Four Domains of Patient Safety Bundles

• Readiness

• Recognition

• Response

• Reporting/Systems Learning

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Key References

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

Consensus StatementHowell EA*, Brown H, Brumley J, Bryant A, Caughey A, Cornell A, Grant JH, Gregory KD, Gullo SM, Kozhimannil KB, Mhyre JM, Toledo P, D’Oria R, Ngoh, M, Grobman WA. Reduction of Peripartum Racial and Ethnic Disparities: A Conceptual Framework and Maternal Safety Consensus Bundle. - Obstet Gynecol. 2018 May;131(5):770-782- J Midwifery Womens Health. 2018 Apr 23. - J Obstet Gynecol Neonatal Nurs. 2018 May;47(3):275-289

THANK YOU

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