OBSTETRIC COMPLICATIONS DURING OBSTETRIC COMPLICATIONS DURING LABOR AND DELIVERY:LABOR AND DELIVERY:

ASSESSING ETHNIC DIFFERENCES IN ASSESSING ETHNIC DIFFERENCES IN CALIFORNIACALIFORNIA

Sylvia Guendelman, Ph.D.Sylvia Guendelman, Ph.D.Dorothy Thornton, Ph.D.Dorothy Thornton, Ph.D.

Jeffrey Gould, M.D., M.P.H.Jeffrey Gould, M.D., M.P.H.Nap Hosang MD, MPH, MBANap Hosang MD, MPH, MBA

University of California, BerkeleyUniversity of California, Berkeley

Expecting Something Better: A Conference Expecting Something Better: A Conference to Optimize Maternal Health Careto Optimize Maternal Health Care

Jacobs InstituteJacobs Institute

May 18,19 2005May 18,19 2005

The Burden of Morbidity During Labor The Burden of Morbidity During Labor and Deliveryand Delivery

Although few women die in childbirth, a recentAlthough few women die in childbirth, a recentnational study conducted by CDC showed that onenational study conducted by CDC showed that oneout of four women experience an obstetricout of four women experience an obstetriccomplication during Labor and Delivery such ascomplication during Labor and Delivery such aspre-eclampsia, eclampsia, hemmorhage, infection,pre-eclampsia, eclampsia, hemmorhage, infection,a major laceration or other obstetric trauma.a major laceration or other obstetric trauma.

Danel, Berg, Johnson & AtrashDanel, Berg, Johnson & AtrashAJPH, 2003, 93:631-634AJPH, 2003, 93:631-634

Normal Pregnancy

Severe Morbidity

Morbidity Near Miss Death

Defining Maternal MorbidityDefining Maternal Morbidity

A maternal morbidity is a physical A maternal morbidity is a physical complication or condition caused by complication or condition caused by the pregnancy itself or by its the pregnancy itself or by its management that is not considered management that is not considered normal during delivery or that cannot normal during delivery or that cannot be adequately managed without be adequately managed without detrimental health effects.detrimental health effects.

Maternal Morbidity During Labor Maternal Morbidity During Labor and Deliveryand Delivery

1.1. Is a new surveillance indicator in Healthy Is a new surveillance indicator in Healthy People 2010People 2010

2.2. Data are needed to assess health disparitiesData are needed to assess health disparities

3.3. Women of color contribute disproportionately Women of color contribute disproportionately to births in the US, yet population data by to births in the US, yet population data by race/ethnicity are not available, especially for race/ethnicity are not available, especially for non-Black women non-Black women

Examining Ethnic Disparities in Examining Ethnic Disparities in Maternal Morbidities in CaliforniaMaternal Morbidities in California

Purpose: Used linked hospital discharge and birth records Purpose: Used linked hospital discharge and birth records data to:data to:

1)1) Compare obstetric complications during labor and Compare obstetric complications during labor and delivery among white non-Latina, Black, Asian and delivery among white non-Latina, Black, Asian and Latina women who delivered in California hospitals Latina women who delivered in California hospitals during 1996-98during 1996-98

2)2) Compare ethnic differences on three indicators Compare ethnic differences on three indicators sensitive to the quality of intrapartum care: postpartum sensitive to the quality of intrapartum care: postpartum hemmorhage, major puerperal infections and major hemmorhage, major puerperal infections and major lacerationslacerations

3)3) Suggest strategies for changeSuggest strategies for change

Conceptual FrameworkConceptual Framework

Socio-demographic characteristics

One or more maternal morbidities

Intrapartum care sensitive conditions

Access to Care

• Age at deliveryAge at delivery• ParityParity• EducationEducation• Prenatal care payment source Prenatal care payment source public or self pay low SES vs.public or self pay low SES vs. private moderate/highprivate moderate/high

• Prenatal care initiationPrenatal care initiation• Quality of obstetric careQuality of obstetric care

Deliveries in California, 1996-98Deliveries in California, 1996-98n=1,426,854n=1,426,854

LatinaLatina WhiteWhite BlacksBlacks AsiansAsians

35%35%

51%51%

7%7% 6.9%6.9%

Table 1: Rates of At Least One Maternal Morbidity and the Three Most Common Maternal Morbidities during Labor and Delivery by Race/Ethnicity.

All Deliveries Latina Black Asian White

1,507,275 723,821 101,396 98,219 503,418

At least One

20.91% 19.57% 24.15% 21.34% 21.28%

Most Common

Major lacerations 4.23%

GU Infections 3.52%

GU Infections 5.47%

Major Lacerations 6.32%

Major lacerations 4.87%

2nd Most Common

GU Infections 3.38%

Major lacerations 3.47%

Pre-eclampsia/Eclampsia 3.88%

Post-partum Hemorrhage 2.70%

GU Infections 2.99%

3rd Most Common

Pre-eclampsia/Eclampsia 2.94%

Pre-eclampsia/Eclampsia 2.95%

Other Infections 3.42%

Puerperal Conditions 2.22%

Pre-eclampsia/Eclampsia 2.89%

Table 2: Odds of One or More Maternal Morbidities During Labor and Delivery

White Asian Latina Black

Observed OR RefRef 1.00 0.99-1.021.00 0.99-1.02 0.92 0.91-0.930.92 0.91-0.93 1.18 1.16-1.201.18 1.16-1.20

Adjusted OR** RefRef 0.95 0.93-0.960.95 0.93-0.96 0.97 0.96-0.98 0.97 0.96-0.98 1.25 1.23-1.271.25 1.23-1.27

**log odds obstcmplany=const+black+asian+Latina+age+par1+seslow+education**log odds obstcmplany=const+black+asian+Latina+age+par1+seslow+education+kotelpnc+lowqual+hiqual+kotelpnc+lowqual+hiqual

Table 3: Intrapartum Care-Sensitive Conditions

Postpartum Hemorrhage

Population White Asian Latina Black

Adjusted Adjusted OROR RefRef 1.06 1.02-1.111.06 1.02-1.11 1.01 0.98-1.041.01 0.98-1.04 1.04 0.99-1.081.04 0.99-1.08

Major Puerperal Infections

Population White Asian Latina Black

Adjusted Adjusted OROR RefRef 1.16 1.08-1.251.16 1.08-1.25 1.19 1.13-1.241.19 1.13-1.24 2.35 2.21-2.492.35 2.21-2.49

Major Lacerations 3rd and 4th Degree

Population White Asian Latina Black

Adjusted Adjusted OR – vag. OR – vag. deliverydelivery RefRef 1.22 1.19-1.261.22 1.19-1.26 0.91 0.89-0.930.91 0.89-0.93 0.63 0.60-0.660.63 0.60-0.66

ConclusionConclusion

1.1. Considerable burden of morbidity for all Considerable burden of morbidity for all women during L & D: One out of five women during L & D: One out of five deliveries had at least one complication.deliveries had at least one complication.

2.2. Black women experience more Black women experience more aggregate morbidities, while Asian and aggregate morbidities, while Asian and Latina women experience fewer Latina women experience fewer aggregate morbidities compared to white aggregate morbidities compared to white women.women.

ConclusionConclusion

3. Asian women however stand a higher risk of 3. Asian women however stand a higher risk of sub-optimal intrapartum care: higher odds of sub-optimal intrapartum care: higher odds of lacerations, puerperal infections and post partum lacerations, puerperal infections and post partum hemorrhage compared to white women. hemorrhage compared to white women. Possible Possible risk factors: interracial marriages, increased BMI, bigger babies, risk factors: interracial marriages, increased BMI, bigger babies, GDD, provider, system-level factors.GDD, provider, system-level factors.

4. All women of color show excess risk of 4. All women of color show excess risk of puerperal infections.puerperal infections.

5. Health disparities can mean decreased quality 5. Health disparities can mean decreased quality of life, loss of economic opportunities and of life, loss of economic opportunities and feelings of discrimination.feelings of discrimination.

Table 4: Rates of at Least One Table 4: Rates of at Least One SevereSevere Maternal Morbidity During L&D by Maternal Morbidity During L&D by

Race/EthnicityRace/Ethnicity

All Deliveries Latina Black Asian White

1,507,275 723,821 101,396 98,219 503,418

13.1% 12.1% 14% 14% 13.4%

*Based on reduced list of OB complications

Can We Expect Something Better?Can We Expect Something Better?

For the amount of investment in prenatalFor the amount of investment in prenatal

care and OB care can we reduce the ratescare and OB care can we reduce the rates

of morbidities and severe morbidities?of morbidities and severe morbidities? How far down can we go?How far down can we go? What will it take?What will it take?

A. Public Health RecommendationsA. Public Health Recommendations

1.1. Raise awareness among providers, Raise awareness among providers, policy makers and women themselves policy makers and women themselves about the level of aggregate morbidity about the level of aggregate morbidity prevailing during L & D.prevailing during L & D.

2.2. That we continue to strengthen That we continue to strengthen surveillance of maternal health to monitor surveillance of maternal health to monitor changes across populations and care changes across populations and care practices nationally, across states and in practices nationally, across states and in diverse localities.diverse localities.

B. Research RecommendationsB. Research Recommendations

1. 1. Inquire about women’s perceptions of these Inquire about women’s perceptions of these morbidities, the impact on the quality of morbidities, the impact on the quality of women’s lives and their satisfaction with the women’s lives and their satisfaction with the obstetric care received. obstetric care received. Future PRAMS surveys could Future PRAMS surveys could include questions that address these substantive issues.include questions that address these substantive issues.

2.2. Through clinical, laboratory and Through clinical, laboratory and epidemiological research, identify best care epidemiological research, identify best care practices and protocols that could be made practices and protocols that could be made available to reduce infections.available to reduce infections.

• Ensure group B Streptococcal infection protocolsEnsure group B Streptococcal infection protocols• ACOG develop guidance on appropriate timing for ACOG develop guidance on appropriate timing for

antibiotic prophylaxis after rupture of membranesantibiotic prophylaxis after rupture of membranes• Assess variation in efficiency of protocols by Assess variation in efficiency of protocols by

ethnicityethnicity

C. Provisions of CareC. Provisions of Care1. Focus on intrapartum care sensitive conditions to 1. Focus on intrapartum care sensitive conditions to

assess ways of improving obstetric care during labor assess ways of improving obstetric care during labor

and delivery, particularly for minority women.and delivery, particularly for minority women. • Hospitals should review cases of intrapartum complications to Hospitals should review cases of intrapartum complications to identify care practices as starting points for continuous quality identify care practices as starting points for continuous quality improvement. improvement. • That these practices be included as quality markers for the That these practices be included as quality markers for the Joint Commission on Accreditation of Healthcare Joint Commission on Accreditation of Healthcare Organizations JCAHO.Organizations JCAHO. 2. With respect to prevention of major lacerations, 2. With respect to prevention of major lacerations,

researchers, physicians and other providers should researchers, physicians and other providers should

consider risk factors in the perineum that makes consider risk factors in the perineum that makes

tearing more likely.tearing more likely.