Maternity outcomes among African-American and other minority women and strategies to improve it
Abstract
The United States is one of only 13 countries in the world where the rate of maternal mortality — the death of a woman related to pregnancy or childbirth up to a year after the end of pregnancy — is now worse than it was 25 years ago. Each year, an estimated 700 to 900 maternal deaths occur in the United States. Black women are three to four times as likely to die from pregnancy-related causes as their white counterparts, according to the Center for Disease Control and Prevention. In addition, black infants in America are more than twice as likely to die as white infants — 11.3 per 1,000 black babies, compared with 4.9 per 1,000 white babies, according to the most recent government data.
Researchers and health care professionals have been looking for answers to the maternity outcomes disparities for decades. Multiple studies have been conducted and variety of reasons and action plans have been proposed. In my Culminating Experience work I want to illustrate the discussed explanations of inequalities in maternity outcomes and to summarize the most promising strategies for reduction of these gaps.
Discussion
The reasons for the black-white divide in both infant and maternal mortality have been debated by researchers and doctors for more than two decades. But recently there has been growing acceptance of what has largely been, for the medical establishment, a shocking idea: for black women in America, an atmosphere of societal and systemic racism can create a kind of toxic physiological stress, resulting in conditions — including hypertension and pre-eclampsia — that lead directly to higher rates of infant and maternal death. And that societal racism is further expressed in a pervasive, longstanding racial bias in health care — including the dismissal of legitimate concerns and symptoms — that can help explain poor birth outcomes even in the case of black women with the most advantages.
Predictive factors (risk and protective) – pathophysiology
High blood pressure and cardiovascular disease are two of the leading causes of maternal death, according to the Centers for Disease Control and Prevention, and hypertensive disorders in pregnancy, including pre-eclampsia, have been on the rise over the past two decades, increasing 72 percent from 1993 to 2014. A Department of Health and Human Services report last year found that pre-eclampsia and eclampsia (seizures that develop after pre-eclampsia) are 60 percent more common in African-American women and more severe.
Women with preexisting hypertension (high blood pressure before pregnancy or within the first 20 weeks of gestation) and gestational hypertension (onset of high blood pressure after 20 weeks of gestation) are at increased risk for preeclampsia/
eclampsia, although many women who develop preeclampsia/ eclampsia have no history of high blood pressure. Other risk factors for preeclampsia/ eclampsia include preexisting diabetes, renal disease, obesity, falling in the youngest or oldest
categories of maternal age, multiple gestations, women giving birth for the first time, and race. Black women are more likely to develop preeclampsia and to experience poorer outcomes associated with the condition, including progression to eclampsia and in rare cases, death.,
* Center for Disease Control and Prevention, Pregnancy Mortality Surveillance System
Figure 1. Maternal death rate
In 2001-2005, their risk of death was seven times higher for black mothers compared to the risk for white mothers. Today, in New York City black mothers are twelve times more likely to die than white mothers. It is believed that widening gap reflects a dramatic improvement for white women but not for blacks. New York City offers a startling example: A 2016 analysis of five years of data found that black, college-educated mothers who gave birth in local hospitals were more likely to suffer severe complications of pregnancy or childbirth than white women who never graduated from high school. The data illustrates the complexity of the problem and points that there is no single connection, e.g. socio-economic factors, to maternal disparities.
Black women are more likely to be uninsured outside of pregnancy, when Medicaid kicks in, and thus more likely to start prenatal care later and to lose coverage in the postpartum period. They are more likely to have chronic conditions such as obesity, diabetes and hypertension that make having a baby more dangerous. The hospitals where they give birth are often the products of historical segregation, lower in quality than those where white mothers deliver, with significantly higher rates of life-threatening complications.
Hospitals
Understanding why racial disparities in maternal outcomes exist is the first step in eliminating them. Most of the research on racial/ethnic disparities in obstetrics has attributed differences in outcomes to social and biological/genetic factors, and has not accounted for the systems within which obstetric care is delivered and how differences in quality of care may contribute to disparities. Howell et. al. found that both black and white patients who delivered in black-serving hospitals had a higher risk of severe maternal morbidity after accounting for patient characteristics. Their findings suggest that quality of care at hospitals that disproportionately serve blacks is lower than quality at low black-serving hospitals.
Dr. Howell ranks hospitals by their proportion of black deliveries among all deliveries. The top 5% of hospitals are defined as high black-serving hospitals, the next 20% as medium black-serving hospitals, and the remaining 75% of hospitals as low black-serving hospitals. Seventy-four percent of black deliveries occurred at high and medium black-serving hospitals. Overall, severe maternal morbidity occurred more frequently among black than white women (25.8 vs. 11.8 per 1000 deliveries, p<.001); after adjusting for the distribution of patient characteristics and comorbidities, this differential declined, but remained elevated (18.8 vs. 13.3per 1000 deliveries respectively, p<.001). Women delivering in high and medium black-serving hospitals had elevated rates of severe maternal morbidity rates compared with those in low black-serving hospitals in unadjusted (29.4, 19.4, versus 12.2 per 1000 deliveries respectively, p<0 .001) and adjusted analyses (17.3, 16.5 vs. 13.5 per 1000 deliveries respectively, p<.001). Black women who delivered at high black-serving hospitals had the highest risk of poor outcomes.
Howell et. al. ranked hospitals by their proportion of black deliveries among all deliveries and chose two cut off points. They defined the top 5% of hospitals as high black-serving hospitals, the next 20% (those in the >5% to <=25% range) as medium black-serving hospitals, and the remaining 75% of hospitals as low black-serving hospitals. 279 hospitals (5%) were designated as high black-serving, 1106 hospitals (20 percent) were designated as medium black-serving, and 4102 (75%) as low black serving. Black-serving hospitals were more likely to be: located in an urban area, located in the South, be a teaching hospital, have a higher delivery volume, have larger bed size, and have a higher proportion of Medicaid deliveries.
Figure 2. US hospitals by the percentage of black-serving population
Prenatal Care
The single measure that reflects quality of obstetrical care is the proportion of women who receive prenatal care in the first trimester. White women and Asian/Pacific Islanders are most likely to receive early prenatal care. In 2006, 69.0% of women received prenatal care in the first trimester; these proportions were 76.2%, 58.4% and 57.7% for whites, blacks and Hispanics, respectively . Contributors to late entry into prenatal care are numerous and include concerns such as lack of education and insurance coverage, ambivalence about pregnancy and negative perceptions of health care providers and staff. Black women are more likely than women from other groups to have unintended pregnancies; women with unintended pregnancies are more likely to present late to care. Black and Hispanic women in the United States are also more likely to be poor and reliant upon public insurance sources. Many of these women are not eligible for Medicaid before pregnancy but become so by virtue of different income eligibility standards set in pregnancy; however, the application process for pregnancy-related coverage may present a barrier to early initiation of care. Women who fail to present for prenatal care entirely are at high risk for adverse pregnancy outcomes and are more likely to be non-White. However, whether maternal behaviors such as late or lack of entry into prenatal care explain a significant portion of racial/ethnic disparities in outcomes is not clear.
Primary Cesarean Sections
Potential quality measures to consider include the primary cesarean delivery rate, prevalence of major obstetrical lacerations, postpartum hemorrhage and puerperal infection, the latter three of which are considered intrapartum care-sensitive conditions. Several studies have documented higher risks of cesarean delivery among non-white women as compared with white women, even after adjusting for features known to be risk factors, such as maternal age, socioeconomic status, pre-existing chronic disease and obstetric complications such as preeclampsia and macrosomia.10
Preterm birth and fetal demise
Dr. Geronimus, a professor at the University of Michigan School of Public Health, created the term “weathering” for stress-induced wear and tear on the body. Weathering causes a lot of different health vulnerabilities and increases susceptibility to infection and early onset of chronic diseases, in particular, hypertension and diabetes — conditions that disproportionately affect blacks at much younger ages than whites. Weathering has profound implications for pregnancy, the most physiologically complex and emotionally vulnerable time in a woman’s life. Stress has been linked to one of the most common and consequential pregnancy complications, preterm birth. Black women are 49 percent more likely than whites to deliver prematurely (and, closely related, black infants are twice as likely as white babies to die before their first birthday). Here again, income and education aren’t protective.
Despite improvements in fetal death rates in the United States over time, significant racial disparities persist. In 2004, the overall fetal death rate was 6.2 deaths per 1,000 live births and fetal deaths; the rate for blacks (11.3/1,000) was more than twice than for non-Hispanic whites (5.0/1,000) . Rates for Hispanic women, Asian/Pacific Islanders and American Indian/Alaska Natives (AI/AN) did not differ much from that of whites. A review of fetal death rates for women enrolled in a large, prospective study of singleton pregnancies demonstrated an adjusted odds ratio (AOR) for fetal death < 24 weeks gestation of 3.2 (95% CI [2.2, 4.8]) for black women as compared to white women, and of 3.1 [1.5, 6.2] for fetal death ≥ 24 weeks gestation.
Figure 3. Percentage of preterm births in the United States
Social Circumstances
The role of social circumstances such as poverty and maternal stress has been explored as contributors to disparities in preterm birth. Poor socioeconomic conditions at the individual and neighborhood levels are associated with prematurity and may modify the effect of race on preterm birth risk. Hispanic women, who often have socioeconomic statuses similar to that of black women, on average, have notably better birth outcomes a phenomenon often referred to as the “Hispanic paradox.”
Postpartum Care
Until recently, much of the discussion about maternal mortality has focused on pregnancy and childbirth. But according to the most recent CDC data, more than half of maternal deaths occur in the postpartum period, and one-third happen seven or more days after delivery. For American women in general, postpartum care can be dangerously inadequate — often no more than a single appointment four to six weeks after going home. The dangers of irregular postpartum care may be particularly great for black mothers. African-Americans have higher rates of C-section and are more than twice as likely to be readmitted to the hospital in the month following the surgery. They have disproportionate rates of hypertensive disorders and peripartum cardiomyopathy (pregnancy-induced heart failure), two leading killers in the days and weeks after delivery. They’re twice as likely as white women to have postpartum depression, which contributes to poor outcomes, but they are much less likely to receive mental health treatment.
Breastfeeding
Despite the many benefits of breastfeeding, African American mothers have the lowest rate of breastfeeding initiation and duration. The Centers for Disease Control and Prevention (CDC) noted that from 2011 to 2015, the percentage of women who initiated breastfeeding was 64.3 percent for African Americans, 81.5 percent for Whites, and 81.9 percent for Hispanics. And while 79.2 percent of infants began breastfeeding, only 20 percent breastfed exclusively for 6 months, and 27.8 percent met the recommended breastfeeding duration of 12 months. The racial disparities are significant and some of the reasons are: (1) African American women tend to return to work earlier after childbirth and are more likely to work in environments that do not support breastfeeding; (2) healthcare settings that provide supplemental feeding to healthy full-term breastfed babies during the postpartum stay decrease the likelihood of exclusive breastfeeding; (3) healthcare settings that separate mothers from babies during their hospital stay; (4) lack of knowledge about the benefits of breastfeeding and the risks of not breastfeeding; (5) perceived inconvenience—a breastfeeding mother may have to give up too many habits of her lifestyle; (6) the mistaken belief that “big is healthy,” leading moms to introduce formula early; (7) the cultural belief that the use of cereal in a bottle will prolong the infant’s sleep; and (8) embarrassment—fearful of being stigmatized when they breastfeed in public19.
Recommendations for improvements
Three quarters of black deliveries in the United States occur in a quarter of the hospitals, and the data suggests that these hospitals may provide lower quality of care. Dr. Howell’s findings highlight the need for targeting quality improvement efforts that address both antenatal and delivery care factors for pregnant women who deliver at these hospitals. This strategy has the potential to improve care for all women who deliver in these hospitals and can have a disproportionate impact on the care of black pregnant women. I have participated in the new study, Dr. Howell and her team conducted in the five boroughs in New York City hospitals, related to the maternity outcomes and the effect of providers and hospitals. After extensive conversations with their team about the quality of care inequality in different hospitals, I was convinced that future research is needed to validate the statement.
In my opinion, hospitals’ participation in the variety of evidence-based quality improvement and performance improvement projects is the key to improve overall maternity outcomes in African-American and black communities. One such program is CenteringPregnancy ©. CenteringPregnancy is an evidence-based model of group prenatal care that has been associated with increased patient satisfaction, lower rates of preterm birth, increased attendance at prenatal and postpartum visits, and higher rates of breastfeeding. In CenteringPregnancy, 8 to 12 pregnant women of similar gestational age meet regularly with a medical provider and another member of the healthcare team to receive physical health assessments, learn care practices, build a support network, and discuss topics related to health, pregnancy and parenting. Partners and other support people are welcomed into the group. Each Centering group is facilitated by a medical provider and another member of the healthcare team such as a nurse, medical assistant, health educator, or social worker. Numerous published studies show that Centering moms have healthier babies and that Centering nearly eliminates racial disparities in preterm birth. Moms are actively engaged in their own healthcare and own their health information. Moms in Centering spend 10x more time with their provider than women in traditional care. Centering moms are better prepared for labor, delivery, and to care for their infant. Practices report fewer after-hours calls and emergency visits from Centering moms because they better understand what is normal during pregnancy and what is cause for concern. In my hospital, the department of Obstetrics and Gynecology sets the goal of making the centering the “opt-out” model for all prenatal patients. The department recognizes improvements in the outcomes related to prematurity, adherence to the prenatal and postpartum visits, and patients’ satisfaction among participants in the program.
The importance of the topic is illustrated not only in the scientific research and hospitals interest. The political aspect of health disparities is felt nationwide and in the New York State. Governor Andrew M. Cuomo announced recently progress on a comprehensive initiative announced earlier this year to target maternal mortality and reduce racial disparities in health outcomes. “New York is committed to ensuring every woman in the state has equal access to high quality healthcare, and this initiative will help break down unnecessary barriers to care,” Governor Cuomo said. The taskforce will continue to provide expert policy advice on improving maternal outcomes, addressing racial and economic disparities and reducing the frequency of maternal mortality and morbidity in New York State. The taskforce is comprised of leading healthcare professionals, local and state politicians as well as other stakeholders and members of the community.
Initiatives that should improve the outcomes and are supported by the highest ranked health and government officials in NYS are: Establishing the Maternal Mortality Review composed of health professionals from a cross-section of stakeholders around the state who serve and/or are representative of the diversity of women statewide, to work in collaboration with the American College of Obstetricians and Gynecologists and the City of New York to review each maternal death in New York State; Launching the Best Practice Summit with Hospitals and OB-GYNs; Piloting the Expansion of Medicaid Coverage for Doulas. Doulas are non-medical birth coaches who assist a woman before, during, or after childbirth if needed. Certified doulas have been shown to increase positive health outcomes, including reducing birth complications for the mother and the baby; Supporting Centering Pregnancy Demonstrations and Expanding the New York State Perinatal Quality Collaborative.
Conclusions
Black women in the United States experience unacceptably poor maternal health outcomes, including disproportionately high rates of death related to pregnancy or childbirth. Both societal and health system factors contribute to high rates of poor health outcomes and maternal mortality for Black women, who are more likely to experience barriers to obtaining quality care and often face racial discrimination throughout their lives.
To begin to eliminate disparities in maternal and infant mortality, several steps must be taken to increase access to high-quality medical care for women of color, particularly during pregnancy, and make sure that all care is patient-centered, culturally appropriate, and listens to women’s needs.
References
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