Racial, Ethnic Disparities in Maternal Mortality, Morbidity Persist

Heidi Splete

January 06, 2021

Racial and ethnic disparities in maternal and infant outcomes persist in the United States, with Black women being 3-4 times more likely to die of pregnancy-related causes, compared with Latina and non-Latina white women, Elizabeth Howell, MD,

Location matters, too, and ethnic disparities appear to transcend class, said Howell of Penn Medicine, Philadelphia. In New York City, for example, Black women are 8-12 times more likely to die than white women regardless of educational attainment.

Howell cited the definitions of health equity and health disparities as defined by Paula Braveman, MD, in 2014 in the journal Public Health Reports, as follows: "Health equity means social justice in health (i.e., no one is denied the possibility to be healthy for belonging to a group that has historically been economically/socially disadvantaged. Health disparities are the metric we use to measure progress toward achieving health equity."

Structural racism and discrimination contribute to disparities in maternal and infant morbidity and mortality in several ways, she said. Patient factors include sociodemographics, age, education, poverty, insurance, marital status, language, and literacy. In addition, a patient's knowledge, beliefs, and health behaviors, as well as stress and self-efficacy are involved. Community factors such as crime, poverty, and community support play a role.

"These factors contribute to the health status of a woman when she becomes pregnant," Howell said. "These factors contribute as the woman goes through the health system."

Then provider factors that impact maternal and infant morbidity and mortality include knowledge, experience, implicit bias, cultural humility, and communication; these factors affect the quality and delivery of neonatal care, and can impact outcomes, Howell said.

"It is really important to note that many of these pregnancy-related deaths are thought to be preventable," she said. "They are often caused by delays in diagnosis, problems with communication, and other system failures. Site care has received a great deal of attention" in recent years, the ob.gyn. noted.

How Hospital Quality Contributes to Health Disparities

Howell shared data from a pair of National Institutes of Health–funded parallel group studies she conducted at New York City hospitals to investigate the contribution of hospital quality to health disparities in severe maternal morbidity and very preterm birth (prior to 32 weeks).

The researchers used vital statistics linked with discharge abstracts for all New York City deliveries between 2011-2013 and 2010-2014. They conducted a logistic regression analysis and ranked hospitals based on metrics of severe maternal morbidity and very preterm birth, and assessed differences by race in each delivery location.

Overall, Black women were almost three times as likely and Latina women were almost twice as likely as White women to experience some type of severe maternal morbidity, with rates of 4.2%, 2.7%, and 1.5%, respectively.

The researchers also ranked hospitals, and found a wide variation; women delivering in the lowest-ranked hospitals had six times the rate of severe maternal morbidity. They also conducted a simulation/thought exercise and determined that the hospital of delivery accounted for approximately 48% of the disparity in severe maternal morbidity between Black and White women.

Results were similar in the parallel study of very preterm birth rates in New York City hospitals, which were 32%, 28%, and 23% for Black, Latina, and White women, respectively.

The researchers also conducted interviews with personnel including chief medical officers, neonatal ICU directors, nurses, and respiratory therapists. The final phase of the research, which is ongoing, is the dissemination of the information, said Howell.

Overall, the high-performing hospitals were more likely to focus on standards and standardized care, stronger nurse/physician communication, greater awareness of the potential impact of racism on care, and greater sharing of performance data.

Women who participated in focus groups reported a range of experiences, but women of color were likely to report poor communication, feeling traumatized, and not being heard.

Study Implications

Howell discussed the implications of her study in a question and answer session. "It is incredibly important for us to think about all the levers that we have to address disparities."

"It is a complex web of factors, but quality of care is one of those mechanisms, and it is something we can do something about," she noted.

In response to a question about whether women should know the rates of adverse outcomes at various hospitals, she said, "I think we have a responsibility to come up with quality of care measures that are informative to the women we care for."

Much of obstetric quality issues focus on overuse of resources, "but that doesn't help us reduce disparities," she said.

Howell had no financial conflicts to disclose.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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