The Ingram/Spellacy Society was founded in 2010 as the alumni group of Ob/Gyn residents, fellows and faculty of the University of South Florida (USF). The purpose of the Society is to share knowledge and promote support for the USF Department in improving the quality of Ob/Gyn care through education and research.

Since its inception, the Society has funded regional lectures and financially supported University of South Florida residents while on electives away from Tampa. The Society has always had close ties with ACOG and is honored to support this annual lectureship at the ACOG District XII 2019 Annual District Meeting.

Maternal Child Health Inequity

Haywood L. Brown, MDProfessor Obstetrics and Gynecology

Associate DeanUniversity South Florida

District XII ACOG

Objectives

At the conclusion of this presentation the participant will be able to:• Discuss health equity and the impact on disparity in the context of

maternal health• Emphasize the impact of bias on maternal outcome for individuals

from vulnerable populations at the clinical, operational and system levels

• Discuss health policy implications for support or lack there of on the quality of maternity child care in the US

Disclosure

• Merck • Manual • Merck for Mother’s Global Advisory Board

• Up to Date• Contributor to publications

Definitions

• Disparity (Healthy People 2010)• the quantity that separates a group from a reference point on a particular

measure of health that is expressed in terms of a rate, proportion, mean, or some other quantitative measure

• often measured from the most favorable group rate• Health inequity (Boston Public Health Commission)

• difference in health that is not only unnecessary and avoidable but, in addition, are considered unfair and unjust

• rooted in social injustices that make some population groups more vulnerable to poor health than other groups.

Research, Ethics and Health Care& Penicillin

TRUST, Research, Ethics and health disparities• TUSKEGEE

• US Public Health Service Tuskegee Untreated Syphilis Study in Negro Men

• Over 40 years lost to follow-up only 17%• 1100 paper published between 1934-1974

Contributors to health and health care inequities

Patient-level factors•Beliefs and preferences•Race/ethnicity, culture, family•Education and resources•Biology

Clinical encounter•Provider communication•Cultural competence

Provider factors•Knowledge and attitudes•Competing demands•Implicit/explicit biases

Health system factors• Health services organization, financing, delivery• Health care organizational culture, QI

Structural factors• Poverty/wealth• Unemployment• Stability of housing• Food security• Racism

Adapted from Kilbourne et al,AJPH 2006

Contributors to health and health care inequities

Patient-level factors•Beliefs and preferences•Race/ethnicity, culture, family•Education and resources•Biology

Clinical encounter•Provider communication•Cultural competence

Provider factors•Knowledge and attitudes•Competing demands•Implicit/explicit biases

Health system factors• Health services organization, financing, delivery• Health care organizational culture, QI

Structural factors• Poverty/wealth• Unemployment• Stability of housing• Food security• Racism Adapted from Kilbourne et al,

AJPH 2006

Racial/ethnic disparities in Ob/GynAI/AN Asian Black Hispanic White

Disparities in health outcomes

Infertility in last 12 months

(% of women)

-- 10 12 9 7

Unintended pregnancy (%

of pregnancies)

-- -- 69 56 42

Preterm birth (% of LB) 14 10 17 12 11

Fetal death (/1,000 live

births+ fetal deaths)

-- -- 11 5 5

Maternal death (/100,000

live births)

-- 10 33 10 11

Gonorrhea (/100,000

population)

96 18 570 -- 24

Breast cancer deaths

(/100,000 population)

16 12 31 15 22

ACOG CO

#649

Trust gaps

• ETIOLOGY OF DISPARITIES IN MATERNAL MORTALITY

“When Landrum complained about how she was feeling more forcefully at the appointment, she recalls, her doctor told her to lie down — and calm down.”

U.S. Maternal and Infant Mortality

U.S. has higher maternal and infant mortality rates than other wealthy countries:

• Ranks 19th of 20 in child mortality• Ranks > 21th in maternal mortality

“Hidden causes” of maternal mortality

Koch, 2016

Maternal Mortality is Preventable

Main et al. Obstet Gynecol 2015;125(4):938-947

Vulnerable populations• US has higher maternal mortality

than Iran, Libya and Turkey• US maternal mortality 2x greater

than Canada• Childbirth number 1 reason for

hospitalization in the US• For every maternal death 50-100

near miss morbidities• 60 maternal deaths postpartum• Black women die at rate of 3 to 4

times that of white women in the US

Disparities in cesarean delivery

Bryant et al, 2010

Role of patient-provider communication?

Role of perception of litigiousness?

Role of implicit provider bias?

Infant Mortality Wealthy Countries

Preterm Birth Report 2016

Prematurity Disparity

• Surgeon General’s Conference (O&G 2009)• Psychosocial and Behavior Consideration

• Research on the effects of race, racism, and social injustice for African Americans must be a priority as they bear the highest burden of prematurity

• Cross Cutting Issues and Conclusion• Dramatic effect of race, ethnicity, and socioeconomic status on the

incidence and severity of preterm birth must stimulate policymakers and funders to implement comprehensive and sustained efforts to eliminate social inequity

FIMR

Rural Hospital Closures

• Many of those hospitals in the South in states that did not expand Medicaid as of January 2017.

• 82% of rural hospital closures (no Medicaid expansion)• Rural Southeastern communities with measurable health disparities

for chronic conditions• Diabetes• Hypertension• obesity

Preventable Maternal Mortality

• Leading causes of maternal death for non-Hispanic black women• Cardiomyopathy (14.0%)• Cardiovascular and coronary conditions (12.8%)• Preeclampsia/eclampsia (11.6%)• Hemorrhage (10.5%)• Embolism (9.3%)

• Deaths with the higher degree of preventability • Cardiovascular and coronary disease ( 68.2%)• Hemorrhage (70%)

• Metz TD, Obstet Gynecol 2018;132:1040-5.

Maternal MortalityPostpartum

More than half of pregnancy-related maternal deaths occur after delivery

Figure 1. Percentage of Maternal Deaths Before, During, After Childbirth

Percentage of Maternal Deaths

Source: Creanga, A. A., Syverson, C., Seed, K., & Callaghan. W. M. (2017). Pregnancy-Related Mortality in the United States, 2011-2013. https://www.ncbi.nlm.nih.gov/pubmed/28697109

Figure 1. Percentage of Maternal Deaths Before, During, After Childbirth

More than half of pregnancy-related maternal deaths occur after delivery

Source: Creanga, A. A., Syverson, C., Seed, K., & Callaghan. W. M. (2017). Pregnancy-Related Mortality in the United States, 2011-2013. https://www.ncbi.nlm.nih.gov/pubmed/28697109

Percentage of Maternal Deaths

Before delivery

Series 10.30499999999999999Day of delivery

Series 10.168000000000000011-6 days postpartum

Series 10.1827-41 days postpartum

Series 10.2129999999999999942-365 days postpartum

Series 10.13200000000000001

Fragmentation of Care

• 50% of all hospitals in US provide care for three or fewer deliveries a day

• Team training for readiness to manage preventable morbidity (i.e. limited blood supply)

• Tighten the partnership with health centers (clinics), hospital and all obstetrical care providers: obstetricians, family physicians, nurse practitioners, midwives)

• telemedicine• Shortage and maldistribution of obstetricians in the US particularly in

rural communities• Specialty and subspecialty consultation

Rural vs Urban Care and Maternal Morbidity

• Lisonkova et al. CMAJ 2016• Results

• British Columbia, Canada comparing mortality and severe morbidity• death and severe maternal morbidity ( OR-1.15, Ci 1.03-1.28) in rural vs

urban• Rural had Higher rate of eclampsia (OR-2.70, Ci 1.79-4.08), embolism (OR-

2.16, CI 1.14-4.07), uterine rupture (OR-1.96, CI 1.42-2.72) than urban women

• Infants in rural more likely to have severe neonatal morbidity (OR- 1.14, CI 1.10-1.19

• Conclusions• Providers in rural areas need to be aware of potential morbidities and

mortality risk.

Understanding Racial Disparities:The Big Picture

Source: Elisabeth Howell, MD, MPP. Reduction of PeripartumDisparities Bundle. 2017.

Maternal Mortality

• Maternal Mortality Review• Preventing Maternal Death Act/ Maternal Health

Accountability Act bipartisan legislation December 2018.

• Provides financial support and infrastructure for state-based maternal mortality review committees to be established and/or strengthened existing multidisciplinary MMRC.

Health Equity

• In an analysis of 23,692 women with Medicaid, predictors of not attending a postpartum visit included:

• Black race• Alcohol or drug use• Mental health disorder other than depression• Living in a neighborhood where a high proportion of

individuals >25 do not have a high school diploma• Ensuring ALL women are engaged in the support they

need following birth is an essential step in achieving health equity

Bennett et al (2014)http://www.ncbi.nlm.nih.gov/pubmed/24474651

Teen BirthSex Education

Page 31

Teen Birth by Race

National Initiative to Reduce Maternal Mortality

and Morbidity Multi-Disciplinary

Multi-Organization“Stewardship”

Implementation to National Scale

Maternal Child Health Bureau

OB Safety Bundles

Obstetric Hemorrhage

Severe Hypertensionin Pregnancy

Maternal VTE Prevention

Patient, Family and Staff Support

Safe Reduction of Primary Cesarean

Births

Reducing Disparities in

Maternity Care

Telemedicine• Summary

• Innovation in health care delivery through telemedicine/tele-heath is evolving at a rapid speed

• Tele- consultation for inpatient and outpatient management is rapidly becoming a modality to improve access and the quality of care in rural and urban setting for all specialties including Obstetrics and Gynecology

• innovations in providing prenatal and postpartum follow up• Obstacles to implementation:

• available technology in many rural settings, cost & reimbursement and liability concerns

Advocacy

Title X is the only federal grant program dedicated solely to providing individuals with comprehensive family planning and related preventive health services.

For more than 40 years, Title X family planning clinics have played a critical role in ensuring access to a broad range of family planning and related preventive health services for millions of low-income or uninsured individuals and others.

Why support for Title IX and maintaining access to contraception under the ACA is importantWorldwide almost 25% of maternal deaths are due to unmet need for contraceptionMain barriers facing promotion of FP services

• Certain religious groups not practicing FP methods instill fear into other ethnic groups with regard to a possible ethnic imbalance in the future

• Lack of facilities in government institutions for sterilizations• Resistance to introduction of newer contraceptive methods such

as PPIUD

Reproductive services: inequity in quality?

• 67% of black women survey reported raced-based discrimination at family planning visits (Thorburn 2005)

• Many rooted in racial stereotypes of reproductive behaviors (e.g. multiple sexual partners assumed)

• Much qualitative and quantitative work describes the pressure women of color perceive to use birth control

• “If you're poor, they like to, you know, make sure you're on birth control. They don't want you having a lot of kids, I guess.” (Gomez, 2017)

• In an RCT, providers more likely to recommend LARC methods to poor Black and Latina women (Dehlendorf, 2010)

American Heart Association Guidelines for CVD Prevention

• Detailed history of pregnancy• Gestational diabetes• Preeclampsia• Preterm birth• Small infant

• Historically screening occurs later in life• Identification during pregnancy maximizes

opportunity for prevention

Circulation March 2011

Critical Factors

• System Leadership • Awareness and assess for risk of pregnancy complications without promoting

fear• Education of patient and providers and shared decision making in obstetrical

care• Awareness of institutional biases that impact obstetrical care at any level that

might impact quality and safety• Adopt and require adherence to best practice guidelines, protocols, and

bundles to reduce risk for morbidity and mortality• Adequate resources for safe and supportive obstetrical care

• Team training, simulation drills for common obstetrical emergencies• Accountability

Health Policy Implications

• Coverage beyond 6 weeks for women with pregnancy complications

• Seamless handover of care• Disseminate to providers, public and

payors• Monitor and incentivize compliance• Fund research to improve lifelong health in

women

Vulnerable Populations (Black women/Maternal Morbidity and MortalitySister Song, Inc• Reproductive Justice

• Maintain personal bodily autonomy

• Have children• Not have children• Parent the children we

have in a safe and sustainable communities

Disparity

• Social inequality kills: • It deprives individuals and communities of a healthy start in life, increases

their burden of disability and disease, and brings early death.• Poverty and discrimination• Inadequate medical care• And violation of human rights

• “All act as powerful social determinants of who lives and who dies, at what age, and with what degree of suffering.”

• Nancy Krieger (2005). Healthy bodies and disparity. Boston Harvard school of Public Health

Conclusions

• Racial/ethnic disparities and inequities in obstetrical health and health care are prevalent and persistent

• Movement beyond documentation of disparities and inequities in obstetrics is critical to their elimination

• Adoption of uniform care standards, recognizing our own biases and understanding of the contribution of social determinants of health (including systemic racism) have particular importance for care and outcomes of women in underserved communities

• We can and should advocate for codifying equity best practices, by legislative action, among others

Health Disparities

Factors in African American Health Disparity

Socio-economic Status

30%

Racism30%

Culture30%

Quality of Care10%

Health InequityRacial Disparity Health Disparities Rooted in

Social Determinates of Health• 400 years since first slaves arrived

on Americas (1619)• 250 years enslavement

• 100 years between Emancipation Proclamation (1863) and Civil Rights Act (1965)

• Jim Crow• Poll Tax

• 2020 • 55 years since Civil Rights Act

Additional References• American Women’s health Care: A patchwork Quilt with Gaps. Clancy

et. Al• JAMA, October 14, 1992;268, No 14: 1918

• A renewed focus on maternal health in the US. NEJM. Nov 2017• Rose L. Molina, MD, MPH, Lydia E. Pace, MD, MPH

• Mann S, Hollier LM, McKay K, Brown HL. What we can do about Maternal Mortality – And how to do it quickly. 2018 N Eng J Med 379:18:1689.

• Moaddab A, Dildy GA, Brown HL, Bateni ZH, Belfort MA, Sangi-Haghpeykar H, Clark SL. Health Care Disparity and State-Specific Pregnancy Related Mortality in the United States, 2005-2016. Obstetrics & Gynecology. 131(4):746, April 2018.

Advocacy, Hill Visits, CLC DXII

Slide Number 1Maternal Child Health InequityObjectivesDisclosureDefinitionsResearch, Ethics and Health Care�& PenicillinContributors to health and health care inequitiesContributors to health and health care inequitiesRacial/ethnic disparities in Ob/GynTrust gapsU.S. Maternal and Infant Mortality“Hidden causes” of maternal mortalityMaternal Mortality is PreventableVulnerable populationsDisparities in cesarean deliverySlide Number 16Slide Number 17Infant Mortality Wealthy CountriesPreterm Birth Report 2016Prematurity DisparityFIMRSlide Number 22Rural Hospital ClosuresPreventable Maternal MortalityMaternal Mortality�PostpartumFragmentation of CareRural vs Urban Care and Maternal MorbidityUnderstanding Racial Disparities:�The Big PictureMaternal MortalityHealth EquityTeen Birth�Sex EducationTeen Birth by RaceSlide Number 33TelemedicineSlide Number 35AdvocacyWhy support for Title IX and maintaining access to contraception under the ACA is important��Reproductive services: inequity in quality?American Heart Association Guidelines for CVD Prevention Critical FactorsSlide Number 41Vulnerable Populations (Black women/Maternal Morbidity and MortalityDisparityConclusionsHealth DisparitiesHealth Inequity�Racial DisparityAdditional ReferencesAdvocacy, Hill Visits, CLC DXII