Maternity Care in New Jersey Maternal Characteristics, Birth … · 2020. 8. 27. · insurance...

Maternity Care in New Jersey Maternal Characteristics, Birth Outcomes & Maternal

Morbidity, 2018

New Jersey Department of HealthHealthcare Quality & Informatics

Health Services Research

Genevieve Lalanne-Raymond, RN, MPH, Research Scientist, Healthcare Quality & InformaticsErin Mayo, DVM, MPH, Research Scientist, Healthcare Quality & Informatics

Mehnaz Mustafa, MPH, MSc, Executive Director Healthcare Quality & InformaticsYannai Kranzler, PhD, Director of Population Health

1

Executive Summary

• Overall maternal health and racial/ethnic disparities:

• Overall health of mothers is worsening while outcomes for infants are improving

• Average age of mothers is increasing, which confers increased rates of comorbidities and risk of complication

• Increasing rates of diabetes (DM), hypertension (HTN), obese/overweight mothers

• Decreasing rates of premature and underweight infants

• Racial and ethnic disparities are evident across many factors that can effect maternal health and outcomes

• Non-Hispanic (NH) Black mothers have higher rates of DM, HTN, preterm and low birthweight infants, and higher rates of Severe Maternal Morbidity

• NH Black mothers are more likely to have Medicaid coverage and have lower rates of prenatal care initiation in first trimester

Maternity Care in New Jersey

______________________________

CONTENTS

Birth and Demographics.….4

Risk Factors…………………..10

Outcomes…….....................13

Complications……………….20

2

*NTSV means Nulliparous (first time mother), Term (37 or more completed weeks of gestation), Singleton (one fetus), and Vertex (head-first presentation of the fetus)

Executive SummaryMethod of delivery/ outcomes

• Cesarean delivery rates continue to be high in 2018; 25% of ALL births are cesareans for which there was no trial of labor

• For mothers that had a previous cesarean delivery, Vaginal Birth After Cesarean (VBAC) rates were 11% while 85% had a repeat cesarean delivery with no trial of labor

• Nulliparous mothers account for 39% of all delivery hospitalizations and 37% of all cesarean deliveries. Of nulliparous mothers that experienced cesarean birth, 50% had no trial of labor

• Variation across birthing hospitals• Wide variation in rates of NTSV* cesarean births, episiotomy and VBAC births are seen across

New Jersey birthing hospitals

• It is important to acknowledge that management of obstetric care may vary across birthing hospitals, therefore, further investigation of maternal care provided at the facility level is paramount.

3

*NTSV means Nulliparous (first time mother), Term (37 or more completed weeks of gestation), Singleton (one fetus), and Vertex (head-first presentation of the fetus)

4Data source: New Jersey Birth Certificate Database, Office of Vital Statistics and Registry, New Jersey

Department of Health

Birth Counts and Fertility RateNew Jersey, 2000 to 2017


Births and Demographics

__________________________

The number of births and fertility rate in New Jersey have been on a downward trend since 2007. Overall, the birth rate dropped 13% from 2000 through 2017. Similarly, the fertility rate has dropped from 63.7 per 1,000 women age 15-44 in 2000 to 59 in 2017, representing a 7% drop in fertility rate.

63.7

65.8

59

115,542

115,920

101,159

90,000

95,000

100,000

105,000

110,000

115,000

120,000

54

56

58

60

62

64

66

68

Nu

mb

er

of

Live

Birth

s

Nu

mb

er o

f Li

ve

Birth

s p

er 1

,000

Wo

me

n A

ge

15

-44

Year

Fertility Rate Birth Counts



______________________

Nearly all births in 2018 occurred in a birthing hospital. Of those that did not occur at a birthing hospital, 71% (almost 3 out of 4 out-of-hospital

births) occurred at home.

Births by LocationNew Jersey, 2018

5Data Source: Vital Information Platform (New Jersey Electronic Birth Certificate Database)

In Hospital

99%

Out of

Hospital

1%

Hospital Out of Hospital

17%

2%

10%

71%

Other

Clinic/DoctorsOffice

FreestandingBirthing Center

Home



_________________________

In 2018, Non-Hispanic White mothers made up nearly half (45%) of all delivery hospitalizations in New Jersey, followed by Hispanic mothers who made up 30%.

Delivery Hospitalizations by Mother’s Race/Ethnicity New Jersey, 2018

6

42,913

12,93110,550

28,350

1,696

NH-White NH-Black Asian Hispanic Other/Multi-race

45% 13% 11% 30% 2%

Data Source: 1. New Jersey Hospital Discharge Data Collection System, Health Care Quality

Assessment, Healthcare Quality and Informatics, NJ Department of Health

2. Vital Information Platform (New Jersey Electronic Birth Certificate Database).

Percentage of Births



___________________________________

The average age of mothers who gave birth in New Jersey hospitals has increased in recent years, from 29 in 2000 (not shown) to 31 in 2018. The percentage of mothers under the age of 25 has decreased, while the percentage of those over the age of 30 increased, reflecting the fact that mothers in NJ are waiting until later in life to have babies.

Delivery Hospitalizations by Mother’s AgeNew Jersey, 2000 and 2018

7

7%3%

17%

13%

25%

25%

31%

34%

17%20%

3% 5%

2000 2018

Pe

rce

nta

ge

of

De

live

ry H

osp

ita

liza

tio

ns



___________________________

In 2018, 31% of delivery hospitalizations were to mothers on Medicaid, compared to 32% in 2016 (not shown) representing a 3% decrease.

In 2018, 65% of delivery hospitalizations were to mothers with private insurance compared to 60% in 2016 (not shown) representing a 8% increase.

When looking at distribution of insurance coverage in each racial/ethnic group, in 2018, 51% of Hispanic women were covered by Medicaid compared to 11.9 % of Asian mothers.

Delivery Hospitalizations by Mother’s InsuranceNew Jersey, 2018

8

Private 65%

Medicaid

31%

Other

0.1%Self-Pay &

Charity

Care

4%




38.0%

11.9%

51.0%

43.9%

17.6%

Other/Multi-race

Asian

Hispanic

NH Black

NH White

Medicaid Coverage Percentage in each

Racial/Ethnic Group, 2018



____________________________

In 2018, 71% of all mothers initiated prenatal care in the first trimester of their pregnancy, which was a minimal improvement over 2016, during which 70% of mothers initiated prenatal care in their first trimester(not shown).

However, racial disparities in the timing of initiation of care were evident, with 80% of Non-Hispanic White mothers starting care in their first trimester, but only 56% of Non-Hispanic Black mothers doing so.

Delivery Hospitalizations by Prenatal Care InitiationNew Jersey, 2018

9




70.9%

19.9%

5.6%

2018

Pe

rcen

tage

of

De

live

ry H

osp

ital

izat

ion

s

3rd Trimester

2nd Trimester

1st Trimester

55.8%

78.4%

62.1%

55.9%

80.0%

First Trimester Prenatal Care Initiation, by Race/Ethnicity, 2018

NH White NH Black Hispanic Asian Other/Multi-race

NJ

71%

10


Risk Factors

_____________________________________

In 2018, 11% of mothers who gave birth at a hospital were diabetic, compared with 10% of mothers in 2016 (not shown), representing a 10% increase. Racial and ethnic disparities were observed with the highest rate of diabetes amongst Asian mothers at 19.4% compared to Non-Hispanic White mothers at 8.7%.

In 2018, 9% of mothers who gave birth at hospital were hypertensive, compared with 8% of mothers in 2016 (not shown), representing a 11% increase. Similarly, racial and ethnic disparities were observed with the highest rate being amongst Non-Hispanic Black mothers (13.7%) and the lowest amongst Asian mothers (5.1%).

Maternal Medical Conditions, by Race/EthnicityNew Jersey, 2018

5.1%

7.5%

5.8%

7.3%

13.7%

Chronic and Gestational Hypertension

NJ

9%

19.4%

8.7%

13.7%

11.5%

9.3%

Chronic and Gestational Diabetes NH Black

Hispanic

Other/Multi-race

NH White

Asian

NJ

11%




11




Pre-pregnancy Body Mass Index (BMI)New Jersey, 2016 and 2018


Risk Factors

_________________________________

There was a small shift in pre-pregnancy Body Mass Index (BMI) towards the obese and overweight categories among NJ mothers from 2016 to 2018.

In 2016, 49.7% of mothers were categorized as overweight or obese before pregnancy, while in 2018 51.8% were overweight or obese.

3.7% 3.0%

46.0% 44.6%

27.6% 28.4%

22.1% 23.4%

2016 2018

Perc

enta

ge o

fD

eliv

ery

Ho

spit

aliz

atio

ns

Underweight Normal Overweight Obese

12


Risk Factors

____________________________________

In 2018, low birth weight babies were born during 6.9% of delivery hospitalizations, which was a 9% drop from 2016 rate of 7.6% (not shown). However, there were large disparities of rates of low birth weight by race/ethnicity, with the greatest rate of low birth weight babies for Non-Hispanic Black mothers.

Similarly, preterm births occurred in 8.5% of delivery hospitalizations, which was a minor drop of 3% from the 2016 rate of 8.8% (not shown). Disparities in rates of preterm births were also seen, with the greatest rates of preterm babies born to Non-Hispanic Black mothers.

Childbirth-Related Quality Measures, by Race/EthnicityNew Jersey, 2018

7.3%

8.3%

6.8%

12.0%

5.1%

Low Birth Weight

NH White

NH Black

Hispanic

Asian

Other/Multi-race

NJ

6.9%

7.1%

8.3%

9.0%

12.5%

7.1%

Preterm Birth

NJ

8.5%




13


Outcomes

________________________

In 2018, the average time between admission to the hospital and delivery for all delivery hospitalizations was 15 hours. However, nulliparous* mothers experienced a much longer average interval between admission and delivery, at 21 hours, compared with multiparous* mothers, whose average time was 11 hours.

*Nulliparous mothers are those that are having their first baby, while multiparous mothers have previously had a baby

Average Time from Admission to Birth, Overall and by ParityNew Jersey, 2018




Admission Delivery

All delivery hospitalizations

Multiparousmothers

Nulliparousmothers

15 hrs.

11 hrs.

21 hrs.

Average time from admission to delivery (hours)

14


Outcomes

___________________________

In 2018, 34.4% of deliveries were cesarean births, a decline from 35.7% in 2016 (not shown).

Of all delivery hospitalizations, 25.9% were cesarean deliveries with no preceding trial of labor. Primary cesareans, most commonly performed in nulliparous (first-time) mothers, accounted for 50% of all cesarean births. Among primary cesarean births, 55% were performed with no trial of labor.

Method of Delivery, All Delivery HospitalizationsNew Jersey, 2018

Vaginal

63.4%

VBAC

2.2%

No Trial Labor,

Primary

Cesarean

9.6%

Trial Labor,

Primary

Cesarean

7.7%

No Trial Labor,

Repeat

Cesarean

16.4%

Trial Labor,

Repeat

Cesarean

0.8%

Cesarean

34.4%




15


Outcomes

___________________________

In 2018, nulliparous* mothers accounted for 39% of all delivery hospitalizations (not shown), and 37.2% of all cesarean births. However, 50% of all nulliparous* cesarean births occurred with no trial of labor.

*Nulliparous mothers are those that are having their first baby, while multiparous mothers have previously had a baby

Cesarean Delivery Hospitalizations by Trial of Labor and ParityNew Jersey, 2018




Nulliparous

No trial of

labor

before

cesarean,

18.5%

Nulliparous

Trial of

labor

before

cesarean,

18.7%

Multiparous

No trial of

labor

before

cesarean,

56.9%

Multiparous

Trial of

labor

before

cesarean,

5.9%

37.2%

16


Outcomes

_________________________________

In 2000, about one in five births was delivered by cesarean (surgical birth) in New Jersey (NJ) and the United states (US). An upward trend in the rate of cesarean deliveries was observed in both NJ and US from 2000 to 2010. Since then, it has been on a downward trend.

In 2018, cesarean delivery rates in NJ were similar across all racial and ethnic groups. The lowest rate was amongst Non-Hispanic White mothers at 31.6% and the greatest rate being amongst Other/Multi-race mothers at 38.4% (not shown).

Total Cesarean Deliveries New Jersey, 2000 to 2018

28%

34%

23%

32%

20

25

30

35

40

45

2000 2005 2010 2018

Ce

sare

an

De

live

ry R

ate

(%

o

f Li

ve

Birth

s)

New Jersey United States



2. New Jersey Electronic Birth Certificate Database

17


Outcomes

_______________________________

NTSV means Nulliparous (first time mother), Term (37 or more completed weeks of gestation), Singleton (one fetus), and Vertex (head-first presentation of the fetus).

In 2018, 20.4% of NJ birthing hospitals met the Healthy People 2020 national target NTSV cesarean rate of 23.9% or less, while 79.6% of birthing hospitals can improve. Rates of cesarean birth among NTSV status mothers varied hospital to hospital from as low as 16% up to 61%.

NTSV Low-Risk Cesarean Rate, by HospitalNew Jersey, 2018

0

10

20

30

40

50

60

70

Nu

mb

er

of N

TSV

Su

rgic

al/

Ce

sare

an

Birth

s

pe

r 1

00

De

live

ry H

osp

ita

liza

tio

ns

49 New Jersey Birthing Hospitals

20.4%

of NJ Hospitals

Meet the

National Target

23.9*

National Target

79.6%

of NJ Hospitals

Can Improve

*National target of 23.9% NTSV rate established in Healthy People 2020




18


Outcomes

_____________________________________

In 2018, of mothers that previously experienced a cesarean delivery, 84.6% of them had a repeat cesarean delivery with no trial of labor. Only 11.4% experienced a VBAC and another 4% had a trial of labor before ultimately delivering via cesarean. Allowing more women a trial labor may increase the VBAC rate and lower the risk of complications associated with surgery.

Method of Delivery for Mothers with Previous Cesarean BirthNew Jersey, 2018




No Trial Labor,

Cesarean

84.6%

Trial Labor,

Cesarean

4.0%VBAC

11.4%

19


Outcomes

________________________________

Among mothers that previously experienced a cesarean delivery, the average vaginal birth after cesarean (VBAC) rate for all 49 birthing hospitals in NJ was 11.4% in 2018, but wide variation in rates across hospitals is evident. Of the 49 birthing hospitals in NJ, 18 hospitals had a VBAC rate greater than the average, and one hospital had a VBAC rate of 0%.

Vaginal Birth After Cesarean (VBAC) Delivery Rate, by HospitalNew Jersey, 2018

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

Vag

inal

Bir

th a

fter

Ces

area

n R

ate

49 Birthing Hospitals in NJ

Statewide averageVBAC rate

11.4%

63% of NJ hospitals havebelow average VBAC rates




20


Complications

_______________________________

In 2018, the statewide average episiotomy* rate at NJ birthing hospitals was 7.6%. Across all hospitals, wide variation of rates was present, with a range of 1% up to 29%. Of the 49 birthing hospitals, 23 had episiotomy rates above the statewide average.

*An episiotomy is a surgical incision that is made in the vaginal opening to widen the space for birth, but the American Congress of Obstetricians and Gynecologists recommends limited use of this procedure.

Episiotomy Rate, by HospitalNew Jersey, 2018




0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Epis

ioto

my

Rat

e (%

)

49 Birthing Hospitals in NJ

Statewide

average

rate 7.6%

21

Severe Maternal Morbidity with and without Blood TransfusionsNew Jersey, 2011 to 2018


Complications

__________________________

In 2018, New Jersey’s total Severe maternal morbidities* (SMM) rate was 192 per 10,000 delivery hospitalizations (including those with blood transfusions), a 7% increase from 2011.

Excluding blood transfusions, the 2018 NJ SMM rate was 67 per 10,000 delivery hospitalizations, a 26% increase from 2011.

*Severe maternal morbidities (SMM) are defined as unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health (CDC).

SM

M p

er

10

,00

0 D

eliv

ery

Ho

spita

liza

tio

ns

125 124 126135 134 134

125

53 57 58 5664

47

67

178 181184

190198

182192

0

50

100

150

200

250

2011 2012 2013 2014 2015 2016 2018

NJ Transfusion rate NJ SMM rate w/o transfusion NJ SMM rate Total

Change from ICD-9 to

ICD-10 on 10/1/15

Data Sources: 1. Healthcare Cost and Utilization Project (HCUP), AHRQ and NJ Hospital Discharge Data

Collection System, Health Care Quality Assessment, Healthcare Quality and Informatics, NJ DOH

2. New Jersey Hospital Discharge Data Collection System, Health Care Quality Assessment, Healthcare Quality

and Informatics, NJ Department of Health


22

Severe Maternal Morbidity, by Race/EthnicityNew Jersey, 2011 to 2018


Complications

__________________________

Racial/ethnic disparities in the rates of Severe maternal morbidities (SMM)* are severe and persistent in NJ. The rate of SMM was more than double for Non-Hispanic Blacks than for Non-Hispanic Whites in 2018 (377 vs 135 per 10,000 Delivery Hospitalizations).

*Severe maternal morbidities (SMM) are defined as unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health (CDC).

SM

M p

er

10

,00

0 D

eliv

ery

Ho

spita

liza

tio

ns

286 288303 298

318 312

377

191202

214204

236

203 201

163

117

169 164152 158

175

138

143

134146 153

134 135

0

50

100

150

200

250

300

350

400

2011 2012 2013 2014 2015 2016 2018

Black Hispanic Asian White

Change from ICD-9 to

ICD-10 on 10/1/15

Data Sources: 1. Healthcare Cost and Utilization Project (HCUP), AHRQ and NJ Hospital Discharge Data

Collection System, Health Care Quality Assessment, Healthcare Quality and Informatics, NJ DOH

2. New Jersey Hospital Discharge Data Collection System, Health Care Quality Assessment, Healthcare Quality

and Informatics, NJ Department of Health


Maternity Care in New Jersey Maternal Characteristics, Birth … · 2020. 8. 27. · insurance...

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