1
|
Norton ME, Risch N. The Inclusion of Race in Prenatal Screening Algorithms. Clin Chem 2024; 70:891-893. [PMID: 38842043 DOI: 10.1093/clinchem/hvae073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 04/24/2024] [Indexed: 06/07/2024]
Affiliation(s)
- Mary E Norton
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, United States
- Institute of Human Genetics, University of California, San Francisco, San Francisco, CA, United States
| | - Neil Risch
- Institute of Human Genetics, University of California, San Francisco, San Francisco, CA, United States
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States
| |
Collapse
|
2
|
Cohen A, Lambert C, Yanik M, Nathan L, Rosenberg HM, Tavella N, Bianco A, Futterman I, Haberman S, Griffin MM, Limaye M, Owens T, Brustman L, Wu H, Dar P, Jessel RH, Doulaveris G. Investigation of health inequities in maternal and neonatal outcomes of patients with placenta accreta spectrum: a multicenter study. Am J Obstet Gynecol MFM 2024; 6:101386. [PMID: 38761887 DOI: 10.1016/j.ajogmf.2024.101386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 04/01/2024] [Accepted: 04/27/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Placenta accreta spectrum is associated with significant maternal and neonatal morbidity and mortality. There is limited established data on healthcare inequities in the outcomes of patients with placenta accreta spectrum. OBJECTIVE This study aimed to investigate health inequities in maternal and neonatal outcomes of pregnancies with placenta accreta spectrum. STUDY DESIGN This multicentered retrospective cohort study included patients with a histopathological diagnosis of placenta accreta spectrum at 4 regional perinatal centers between January 1, 2013, and June 30, 2022. Maternal race and ethnicity were categorized as either Hispanic, non-Hispanic Black, non-Hispanic White, or Asian or Pacific Islander. The primary outcome was a composite adverse maternal outcome: transfusion of ≥4 units of packed red blood cells, vasopressor use, mechanical ventilation, bowel or bladder injury, or mortality. The secondary outcomes were a composite adverse neonatal outcome (Apgar score of <7 at 1 minute, morbidity, or mortality), gestational age at placenta accreta spectrum diagnosis, and planned delivery by a multidisciplinary team. Multivariable logistic regression was used to estimate the associations of race and ethnicity with maternal and neonatal outcomes. RESULTS A total of 408 pregnancies with placenta accreta spectrum were included. In 218 patients (53.0%), the diagnosis of placenta accreta spectrum was made antenatally. Patients predominantly self-identified as non-Hispanic White (31.6%) or non-Hispanic Black (24.5%). After adjusting for institution, age, body mass index, income, and parity, there was no difference in composite adverse maternal outcomes among the racial and ethnic groups. Similarly, adverse neonatal outcomes, gestational age at prenatal diagnosis, rate of planned delivery by a multidisciplinary team, and cesarean hysterectomy were similar among groups. CONCLUSION In our multicentered placenta accreta spectrum cohort, race and ethnicity were not associated with inequities in composite maternal or neonatal morbidity, timing of diagnosis, or planned multidisciplinary care. This study hypothesized that a comparable incidence of individual risk factors for perinatal morbidity and geographic proximity reduces potential inequities that may exist in a larger population.
Collapse
Affiliation(s)
- Alexa Cohen
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY (Cohen, Lambert, Yanik, Nathan, Dar, and Doulaveris).
| | - Calvin Lambert
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY (Cohen, Lambert, Yanik, Nathan, Dar, and Doulaveris); Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY (Lambert, Rosenberg, Tavella, and Bianco)
| | - Megan Yanik
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY (Cohen, Lambert, Yanik, Nathan, Dar, and Doulaveris)
| | - Lisa Nathan
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY (Cohen, Lambert, Yanik, Nathan, Dar, and Doulaveris)
| | - Henri M Rosenberg
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY (Lambert, Rosenberg, Tavella, and Bianco)
| | - Nicola Tavella
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY (Lambert, Rosenberg, Tavella, and Bianco)
| | - Angela Bianco
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY (Lambert, Rosenberg, Tavella, and Bianco)
| | - Itamar Futterman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maimonides Medicine Center, Brooklyn, NY (Futterman and Haberman)
| | - Shoshana Haberman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maimonides Medicine Center, Brooklyn, NY (Futterman and Haberman)
| | - Myah M Griffin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY (Griffin, Limaye, and Jessel)
| | - Meghana Limaye
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY (Griffin, Limaye, and Jessel)
| | - Thomas Owens
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Icahn School of Medicine at Mount Sinai West, New York, NY (Owens and Brustman)
| | - Lois Brustman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Icahn School of Medicine at Mount Sinai West, New York, NY (Owens and Brustman)
| | - Haotian Wu
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, NY (Wu)
| | - Pe'er Dar
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY (Cohen, Lambert, Yanik, Nathan, Dar, and Doulaveris)
| | - Rebecca H Jessel
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY (Griffin, Limaye, and Jessel)
| | - Georgios Doulaveris
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY (Cohen, Lambert, Yanik, Nathan, Dar, and Doulaveris)
| |
Collapse
|
3
|
Polavarapu M, Odems DS, Banks S, Singh S. Role of Obstetric Violence and Patient Choice: Factors Associated With Episiotomy. J Midwifery Womens Health 2024. [PMID: 38794803 DOI: 10.1111/jmwh.13655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/07/2024] [Indexed: 05/26/2024]
Abstract
INTRODUCTION In the United States, 1 in 6 women reports obstetric violence in the form of physical and verbal abuse, coercion, and lack of informed consent. Despite recommendations against routine episiotomy, its use in the United States remains notable and varies considerably. This study aimed to analyze the various forms of obstetric violence associated with undergoing an episiotomy and having a choice in undergoing an episiotomy. METHODS Data from the cross-sectional Listening to Mothers in California survey were analyzed using weighted sample. Logistic regression models were conducted to compute adjusted odds ratios (aORs) and 95% CIs for undergoing episiotomy and having a choice in it. RESULTS Overall, 21% of the respondents reported undergoing an episiotomy, and 75% of them reported not having a choice in undergoing this procedure. After adjusting for covariates, feeling pressured to induce labor (aOR, 1.31; 95% CI, 1.28-1.35) and to use an epidural analgesia (aOR, 1.82; 95% CI, 1.77-1.88) increased the odds of undergoing an episiotomy. Having a midwife during childbirth significantly reduced the odds of an episiotomy. Respondents who indicated being handled roughly by health care providers were 95% less likely to have a choice in receiving an episiotomy (aOR, 0.05; 95% CI, 0.04-0.06). DISCUSSION This is the first study to examine other forms of obstetric violence as correlates of episiotomy and having a choice in it. Standardized institutional measures against obstetric violence, patients' ability to make autonomous decisions through informed consent, and engaging midwives could decrease medically unnecessary labor procedures and associated complications.
Collapse
Affiliation(s)
| | - Dorian S Odems
- Department of Population Health, The University of Toledo, Toledo, Ohio
- Department of Human Ecology, University of California, Davis, California
| | - Sativa Banks
- Department of Population Health, The University of Toledo, Toledo, Ohio
| | - Shipra Singh
- Department of Population Health, The University of Toledo, Toledo, Ohio
| |
Collapse
|
4
|
Gulersen M, Alvarez A, Suarez F, Kouba I, Rochelson B, Combs A, Nimaroff M, Blitz MJ. Risk of Severe Maternal Morbidity Associated with Maternal Comorbidity Burden and Social Vulnerability. Am J Perinatol 2024; 41:e3333-e3340. [PMID: 38057088 DOI: 10.1055/a-2223-3602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
OBJECTIVE We evaluated the associations of the obstetric comorbidity index (OB-CMI) and social vulnerability index (SVI) with severe maternal morbidity (SMM). STUDY DESIGN Multicenter retrospective cohort study of all patients who delivered (gestational age > 20 weeks) within a university health system from January 1, 2019, to December 31, 2021. OB-CMI scores were assigned to patients using clinical documentation and diagnosis codes. SVI scores, released by the Centers for Disease Control and Prevention (CDC), were assigned to patients based on census tracts. The primary outcome was SMM, based on the 21 CDC indicators. Mixed-effects logistic regression was used to model the odds of SMM as a function of OB-CMI and SVI while adjusting for maternal race and ethnicity, insurance type, preferred language, and parity. RESULTS In total, 73,518 deliveries were analyzed. The prevalence of SMM was 4% (n = 2,923). An association between OB-CMI and SMM was observed (p < 0.001), where OB-CMI score categories of 1, 2, 3, and ≥4 were associated with higher odds of SMM compared with an OB-CMI score category of 0. In the adjusted model, there was evidence of an interaction between OB-CMI and maternal race and ethnicity (p = 0.01). After adjusting for potential confounders, including SVI, non-Hispanic Black patients had the highest odds of SMM among patients with an OB-CMI score category of 1 and ≥4 compared with non-Hispanic White patients with an OB-CMI score of 0 (adjusted odds ratio [aOR] = 2.76, 95% confidence interval [CI]: 2.08-3.66 and aOR = 10.07, 95% CI: 8.42-12.03, respectively). The association between SVI and SMM was not significant on adjusted analysis. CONCLUSION OB-CMI was significantly associated with SMM, with higher score categories associated with higher odds of SMM. A significant interaction between OB-CMI and maternal race and ethnicity was identified, revealing racial disparities in the odds of SMM within each higher OB-CMI score category. SVI was not associated with SMM after adjusting for confounders. KEY POINTS · OB-CMI was significantly associated with SMM.. · Racial disparities were seen within each OB-CMI score group.. · SVI was not associated with SMM on adjusted analysis..
Collapse
Affiliation(s)
- Moti Gulersen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alejandro Alvarez
- Biostatistics Unit, Office of Academic Affairs, Northwell Health, New Hyde Park, New York
| | - Fernando Suarez
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Insaf Kouba
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, South Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Bay Shore, New York
| | - Burton Rochelson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Adriann Combs
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Michael Nimaroff
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Matthew J Blitz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, South Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Bay Shore, New York
| |
Collapse
|
5
|
Rayas MS, Munoz JL, Boyd A, Kim J, Mangold C, Moreira A. Impact of Race/Ethnicity and Insurance Status on Obstetric Outcomes: Secondary Analysis of the NuMoM2b Study. Am J Perinatol 2024; 41:e2907-e2918. [PMID: 37935375 PMCID: PMC11074238 DOI: 10.1055/s-0043-1776345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
OBJECTIVE This study aimed to investigate the impact of race/ethnicity and insurance status on obstetric outcomes in nulliparous women. STUDY DESIGN Secondary analysis of the Nulliparous Pregnancy Outcomes Study Monitoring Mothers-To-Be. Obstetric outcomes included the development of a hypertensive event during pregnancy, need for a cesarean section, delivery of a preterm neonate, and postpartum hemorrhage. RESULTS Of 7,887 nulliparous women, 64.7% were non-Hispanic White (White), 13.4% non-Hispanic Black (Black), 17.8% Hispanic, and 4.1% were Asian. Black women had the highest rates of developing new-onset hypertension (32%) and delivering preterm (11%). Cesarean deliveries were the highest in Asian (32%) and Black women (32%). Individuals with government insurance were more likely to deliver preterm (11%) and/or experience hemorrhage after delivery. In multivariable analyses, race/ethnicity was associated with hypertension and cesarean delivery. More important, the adjusted odds ratios for preventable risk factors, such as obesity, diabetes, and severe anemia were greater than the adjusted odds ratios for race/ethnicity in terms of poor maternal outcome. CONCLUSION Although disparities were observed between race/ethnicity and obstetric outcomes, other modifiable risk factors played a larger role in clinical differences. KEY POINTS · Race or insurance alone had mixed associations with maternal morbidities.. · Race and insurance had low associations with maternal morbidities.. · Other, modifiable risk factors may be more important.. · Both social and biological factors impact health disparities..
Collapse
Affiliation(s)
- Maria S. Rayas
- Department of Pediatrics, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Jessian L. Munoz
- Department of Obstetrics and Gynecology, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Angela Boyd
- Department of Obstetrics and Gynecology, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Jennifer Kim
- Department of Pediatrics, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Cheyenne Mangold
- Department of Pediatrics, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Alvaro Moreira
- Department of Pediatrics, University of Texas Health Science Center San Antonio, San Antonio, Texas
| |
Collapse
|
6
|
Hacker FM, Phillips JM, Lemon LS, Simhan HN. The Contribution of Neighborhood Context to the Association of Race with Severe Maternal Morbidity. Am J Perinatol 2024; 41:e2151-e2158. [PMID: 37364596 DOI: 10.1055/s-0043-1770704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
OBJECTIVE Severe maternal morbidity (SMM) has disproportionate frequencies among racial minorities and those of socioeconomic disadvantage, with people of Black race consistently having the highest proportion. Neighborhood level deprivation has been associated with maternal morbidity and mortality, including adverse pregnancy outcomes. We sought to explore the relationship between neighborhood socioeconomic disadvantage and SMM and describe how neighborhood context impacts the relationship between race and SMM. STUDY DESIGN We performed a retrospective cohort analysis of all delivery admissions in a single health care network from 2015 to 2019. Area deprivation index (ADI) was used to represent neighborhood socioeconomic disadvantage and is a composite index of neighborhood that spans income, education, household characteristics, and housing. The index ranges from 1 to 100 with higher values indicating higher disadvantage. Logistic regression assessed the relationship between ADI and SMM and estimated the effect that ADI has on the relationship between race and SMM. RESULTS Of the 63,208 birthing persons in our cohort, the unadjusted incidence of SMM was 2.2%. ADI was significantly associated with SMM, with higher values conferring higher risk for SMM (p < 0.001). The absolute risk of SMM increased roughly by 1.0% from the lowest to highest ADI value. Those of Black race had the highest unadjusted incidence of SMM compared with the referent group (3.4 vs. 2.0%) and highest median ADI (92; interquartile range [IQR]: 20). In the multivariable model, in which the primary exposure was race and ADI was adjusted for, Black race had a 1.7 times odds SMM when compared with White race (95% confidence interval [CI]: 1.5-1.9). This association was attenuated to 1.5 adjusted odds when controlling for ADI (95% CI: 1.3-1.7). Risk attenuation for SMM was not seen in other race categories. CONCLUSION Neighborhood context contributes to SMM but does not explain the majority of racial disparities. KEY POINTS · Neighborhood context is associated with SMM, with higher disadvantage conferring higher risk.. · Compared with White race, all other races had higher rates of SMM, with Black race having the highest.. · Accounting for neighborhood modestly attenuates the magnitude of association of Black race with SMM.. · Neighborhood context contributes to health outcomes but does not explain the majority of disparities..
Collapse
Affiliation(s)
- Francis M Hacker
- Department of Obstetrics, Gynecology and Reproductive Science, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | - Jaclyn M Phillips
- Department of Obstetrics, Gynecology and Reproductive Science, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | - Lara S Lemon
- Department of Obstetrics, Gynecology and Reproductive Science, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania
- Department of Clinical Analytics, University of Pittsburgh Medical Center, Clinical Analytics, Pittsburgh, Pennsylvania
| | - Hyagriv N Simhan
- Department of Obstetrics, Gynecology and Reproductive Science, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania
| |
Collapse
|
7
|
Kern-Goldberger AR, Malhotra T, Zera CA. Society for Maternal-Fetal Medicine Special Statement: Utilizing telemedicine to address disparities in maternal-fetal medicine: a call to policy action. Am J Obstet Gynecol 2024; 230:B6-B11. [PMID: 37926134 DOI: 10.1016/j.ajog.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
The combination of deserts in maternal-fetal medicine coverage across the United States and the COVID-19 pandemic accelerated the implementation of telemedicine programs for maternal-fetal medicine care delivery. Although telemedicine-based care has the potential to facilitate timely access to maternal-fetal medicine services, which can improve maternal and neonatal outcomes, telemedicine is a relatively novel healthcare modality that needs to be implemented strategically. As with any medical service, telemedicine care requires rigorous evaluation to assess outcomes and ensure quality. Important health policy considerations, including access to services and insurance coverage, have substantial implications for equity in the implementation of telemedicine, particularly for reproductive healthcare following the 2022 United States Supreme Court decision in Dobbs v Jackson Women's Health Organization that overturned the constitutional right to an abortion. Investing resources and advocating for a rigorous, widely accessible telemedicine infrastructure at this crucial moment will establish an important foundation for more equitable pregnancy care. Key advocacy priorities for maternal-fetal medicine telemedicine include (1) expanding insurance coverage of telemedicine across payers, regardless of geographic location; (2) advocating for interstate licensure parity; (3) increasing access to affordable Internet and digital literacy training; and (4) ensuring access to reproductive healthcare, including abortion care, delivered via telemedicine.
Collapse
Affiliation(s)
- Adina R Kern-Goldberger
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Tani Malhotra
- Division of Maternal-Fetal Medicine, XXX, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Chloe A Zera
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| |
Collapse
|
8
|
Wong MS, Wells M, Zamanzadeh D, Akre S, Pevnick JM, Bui AAT, Gregory KD. Applying Automated Machine Learning to Predict Mode of Delivery Using Ongoing Intrapartum Data in Laboring Patients. Am J Perinatol 2024; 41:e412-e419. [PMID: 35752169 DOI: 10.1055/a-1885-1697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE This study aimed to develop and validate a machine learning (ML) model to predict the probability of a vaginal delivery (Partometer) using data iteratively obtained during labor from the electronic health record. STUDY DESIGN A retrospective cohort study of deliveries at an academic, tertiary care hospital was conducted from 2013 to 2019 who had at least two cervical examinations. The population was divided into those delivered by physicians with nulliparous term singleton vertex (NTSV) cesarean delivery rates <23.9% (Partometer cohort) and the remainder (control cohort). The cesarean rate among this population of lower risk patients is a standard metric by which to compare provider rates; <23.9% was the Healthy People 2020 goal. A supervised automated ML approach was applied to generate a model for each population. The primary outcome was accuracy of the model developed on the Partometer cohort at 4 hours from admission to labor and delivery. Secondary outcomes included discrimination ability (receiver operating characteristics-area under the curve [ROC-AUC]), precision-recall AUC, and calibration of the Partometer. To assess generalizability, we compared the performance and clinical predictors identified by the Partometer to the control model. RESULTS There were 37,932 deliveries during the study period; after exclusions, 9,385 deliveries were included in the Partometer cohort and 19,683 in the control cohort. Accuracy of predicting vaginal delivery at 4 hours was 87.1% for the Partometer (ROC-AUC: 0.82). Clinical predictors of greatest importance in the stacked Intrapartum Partometer Model included the Admission Model prediction and ongoing measures of dilatation and station which mirrored those found in the control population. CONCLUSION Using automated ML and intrapartum factors improved the accuracy of prediction of probability of a vaginal delivery over both previously published models based on logistic regression. Harnessing real-time data and ML could represent the bridge to generating a truly prescriptive tool to augment clinical decision-making, predict labor outcomes, and reduce maternal and neonatal morbidity. KEY POINTS · Our ML-based model yielded accurate predictions of mode of delivery early in labor.. · Predictors for models created on populations with high and low cesarean rates were the same.. · A ML-based model may provide meaningful guidance to clinicians managing labor..
Collapse
Affiliation(s)
- Melissa S Wong
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Informatics, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
| | - Matthew Wells
- Enterprise Data Intelligence, Cedars-Sinai Medical Center, Los Angeles, California
| | - Davina Zamanzadeh
- Medical and Imaging Informatics (MII) Group, Department of Radiological Sciences, University of California Los Angeles, Los Angeles, California
| | - Samir Akre
- Medical and Imaging Informatics (MII) Group, Department of Radiological Sciences, University of California Los Angeles, Los Angeles, California
| | - Joshua M Pevnick
- Division of Informatics, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Alex A T Bui
- Medical and Imaging Informatics (MII) Group, Department of Radiological Sciences, University of California Los Angeles, Los Angeles, California
- Department of Bioengineering, University of California Los Angeles, Los Angeles, California
| | - Kimberly D Gregory
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
- Department of Community Health Sciences, Los Angeles, California Fielding School of Public Health, Los Angeles, California
| |
Collapse
|
9
|
Ragunanthan NW, Lamb J, Hauspurg A, Beck S. Assessment of Racial Disparities in Aspirin Prophylaxis for Preeclampsia Prevention. Am J Perinatol 2024; 41:635-640. [PMID: 35189651 PMCID: PMC9900494 DOI: 10.1055/s-0042-1743142] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Low-dose aspirin is recommended for preeclampsia prevention among women with high-risk conditions, including chronic hypertension. Black women have higher rates of hypertensive disorders of pregnancy, and whether this is related to disparities in aspirin prophylaxis is unknown. We investigated the relationship between race and counseling/prescription and uptake of aspirin among a cohort of women with chronic hypertension. STUDY DESIGN This is a single-institution, retrospective cohort study of women with chronic hypertension who delivered between 2016 and 2018. Medical record review was performed to assess counseling/prescription of aspirin prophylaxis and self-reported uptake. Self-reported uptake was determined by mention in the provider's notes or by inclusion in the medication reconciliation system. Demographic and obstetric outcome data were compared by self-reported race (Black vs. all other races) in univariate analysis. Multivariable logistic regression analysis was performed to evaluate the association between race and aspirin adherence. RESULTS We included 872 women: 361 (41.4%) Black women and 511 (58.6%) white or other race women. Overall, 567 (65.0%) women were counseled and/or given a prescription for aspirin, and 411 (72.4%) of those women reported uptake. Black women were equally likely to be counseled and/or prescribed aspirin compared with all other races (67.3 vs. 63.4%; p = 0.7). However, Black women were less likely to report uptake of aspirin (63.8 vs. 79.0%; p < 0.001). After adjustment for total prenatal visits and tobacco use, Black race was associated with an adjusted odds ratio of 0.53 (95% confidence interval: 0.36-0.78) for uptake of aspirin. CONCLUSION In our cohort, recommendation for aspirin prophylaxis was suboptimal in all groups, reaching only 65% of eligible women. Black women were equally likely as women of other races to receive counseling about aspirin, but rates of uptake were lower. Our findings suggest that counseling and prescription of aspirin alone in high-risk Black women are not sufficient for utilization of this intervention. KEY POINTS · Rates of counseling about aspirin prophylaxis for preeclampsia did not vary by race.. · Black women had lower rates of uptake of aspirin compared with women of other races.. · Counseling about aspirin was inadequate in general, reaching only 65% of eligible women..
Collapse
Affiliation(s)
- Nina W. Ragunanthan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jordan Lamb
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alisse Hauspurg
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stacy Beck
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|
10
|
MacDonald EJ, Lawton B, Storey F, Stevenson K, Tait JD, Stone P. Severe maternal morbidity - we need more action to prevent harm. Aust N Z J Obstet Gynaecol 2024; 64:85-87. [PMID: 38549222 DOI: 10.1111/ajo.13813] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 03/14/2024] [Indexed: 04/18/2024]
Affiliation(s)
- Evelyn Jane MacDonald
- National Centre for Women's Health Research Aotearoa, Victoria University of Wellington, Wellington, New Zealand
| | - Beverley Lawton
- National Centre for Women's Health Research Aotearoa, Victoria University of Wellington, Wellington, New Zealand
| | - Francesca Storey
- National Centre for Women's Health Research Aotearoa, Victoria University of Wellington, Wellington, New Zealand
| | - Kendall Stevenson
- National Centre for Women's Health Research Aotearoa, Victoria University of Wellington, Wellington, New Zealand
| | - John David Tait
- Women's Health Department, Wellington Hospital, Wellington, New Zealand
| | - Peter Stone
- Department of Obstetrics and Gynaecology, Auckland University, Auckland, New Zealand
| |
Collapse
|
11
|
Sutter C, Freundlich RE, Raymond BL, Osmundson S, Morton C, McIlroy DR, Shotwell M, Feng X, Bauchat JR. Effectiveness of Oral Iron Therapy in Anemic Inpatient Pregnant Women: A Single Center Retrospective Cohort Study. Cureus 2024; 16:e56879. [PMID: 38659546 PMCID: PMC11041524 DOI: 10.7759/cureus.56879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2024] [Indexed: 04/26/2024] Open
Abstract
Background and aim Oral iron therapy is effective in treating iron deficiency anemia in outpatient pregnant women but has not been studied in inpatient pregnant women. We aimed to evaluate the effect of oral iron therapy versus no therapy during hospitalization on maternal and neonatal outcomes in women with anemia who are hospitalized for pregnancy-related morbidities (i.e., preterm premature rupture of membranes, preterm labor, pre-eclampsia, abnormal placentation, or fetal monitoring). Methods A retrospective, single-center study was conducted in hospitalized pregnant women (2018 to 2020) with inpatient stays of more than three days. The primary outcome was a change in hemoglobin level from admission to delivery in women treated with oral iron compared with those left untreated. Secondary outcomes included the total amount of iron administered before delivery, the time interval from admission to delivery, and neonatal effects. Results Two hundred sixty-three women were admitted, 79 women had anemia, and 29 (36.7%) received at least one dose of oral iron. Baseline patient characteristics were similar between groups. The median (interquartile range) dose of iron in the oral iron group was 1185.0 (477.0, 1874.0) mg. Neither absolute hemoglobin before delivery (control group: 10.0±1.2 g/dL; iron group: 10.1±1.1 g/dL; p=0.774) nor change in hemoglobin from admission to delivery (control group: -0.1±1.1 g/dL vs. iron group: 0.4±1.1 g/dL; p=0.232) differed between groups. Women in the control group had shorter length of stay (LOS) median (IQR) than women in the iron group (control group: 7.1 (5.0, 13.7) days; iron group: 11.4 (7.4, 25.9) days; p=0.03). There were no differences in maternal mode of delivery, though each group had high rates of cesarean delivery (control group: 53.7%; iron group: 72.4%; p=0.181). There were no differences in estimated blood loss at delivery (control group: 559±401; iron group: 662.1±337.4;p=0.264) in either group. Neonatal birthweight (control group: 1.9±0.7 kg; iron group: 1.9±0.7 kg; p=0.901), birth hemoglobin (control group: 16.3±2.2 g/dL; iron group: 16±2.2 g/dL; p=0.569), neonatal intensive care unit (NICU) admission (control group: 93.3%; iron group: 84.8%;p=0.272 ), or neonatal death (control group: 8.9%; iron group: 3%; p=0.394) were not different between groups. Conclusions Oral iron administered to anemic inpatient pregnant women was not associated with higher hemoglobin concentrations before delivery. Lack of standardized iron regimens and short hospital stays may contribute to the inefficacy of oral iron for this inpatient pregnant population. The small sample size and retrospective nature of this study are limiting factors in drawing conclusive evidence from this study.
Collapse
Affiliation(s)
- Claire Sutter
- Anesthesiology, Vanderbilt University Medical Center, Nashville, USA
| | | | - Britany L Raymond
- Anesthesiology, Vanderbilt University Medical Center, Nashville, USA
| | - Sarah Osmundson
- Maternal Fetal Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Colleen Morton
- Hematology, Vanderbilt University Medical Center, Nashville, USA
| | - David R McIlroy
- Anesthesiology, Vanderbilt University Medical Center, Nashville, USA
| | - Matthew Shotwell
- Biostatistics, Vanderbilt University Medical Center, Nashville, USA
| | - Xiaoke Feng
- Biostatistics, Vanderbilt University Medical Center, Nashville, USA
| | | |
Collapse
|
12
|
Nicole Teal E, Baer RJ, Jelliffe-Pawlowski L, Mengesha B. Racial Disparities in Cesarean Delivery Rates: Do Hospital-Level Factors Matter? Am J Perinatol 2024; 41:375-382. [PMID: 37913783 DOI: 10.1055/s-0043-1776346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVE This study aimed to assess whether racial disparities in nulliparous, term, singleton, vertex cesarean delivery rates vary among hospitals of different type (academic vs. nonacademic), setting (urban vs. rural), delivery volume, and patient population. STUDY DESIGN This is a retrospective cohort study including singleton term vertex live births in nulliparous Black and non-Hispanic White birthing people in California between 2011 and 2017. Cesarean delivery rates were obtained using birth certificate data and International Classification of Diseases, 9th/10th Revision codes. Risk of cesarean delivery was compared among Black versus White birthing people by hospital type (academic, nonacademic), setting (rural, suburban, urban), volume (< 1,200, 1,200-2,300, 2,400-3,599, ≥3,600 deliveries annually), and patient population (proportion Black-serving). Federal Information Processing codes were used to designate hospital setting. Risks were calculated using univariable and multivariable logistic regression and adjusted for birthing person age, body mass index, medical comorbidities, gestational age, labor type (spontaneous vs. induction), and infant birthweight. RESULTS The sample included 59,441 Black (cesarean delivery rate: 30.2%) and 363,624 White birthing people (cesarean delivery rate: 26.1%). Black birthing people were significantly more likely than White birthing people to have a cesarean delivery across nearly all hospital-level factors considered with adjusted relative risks ranging from 1.1 to 1.3. The only exception was rural settings in which the adjusted relative risk was 1.3 but did not reach statistical significance. CONCLUSION Black-White disparities in nulliparous, term, singleton, vertex cesarean delivery rates were persistent across all hospital-level factors we considered: academic status, rurality, delivery volume, and patient population. Furthermore, disparities existed at roughly the same magnitude regardless of hospital characteristics. These global increased risks likely reflect structural inequities in care, which contribute to disparities in pregnancy-related morbidity and mortality. These data should encourage providers, hospital systems, and quality collaboratives to further investigate racial disparities in cesarean delivery rates and develop strategies for eliminating them. KEY POINTS · Nulliparous Black birthing people are more likely than White to undergo cesarean delivery.. · This persists across hospitals of all academic status, rurality, delivery volume, and patient population.. · These findings likely reflect structural rather than institutional inequities in obstetric care..
Collapse
Affiliation(s)
- E Nicole Teal
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Diego, San Diego, California
| | - Rebecca J Baer
- California Preterm Birth Initiative, University of California, San Francisco, San Francisco, California
| | - Laura Jelliffe-Pawlowski
- California Preterm Birth Initiative, University of California, San Francisco, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Biftu Mengesha
- California Preterm Birth Initiative, University of California, San Francisco, San Francisco, California
| |
Collapse
|
13
|
Ragsdale AS, Al-Hammadi N, Bass S, Chavan NR. Racial and Ethnic Disparities Among Pregnancies with Substance Use Disorder: Impact on Perinatal Outcomes. J Womens Health (Larchmt) 2024. [PMID: 38407821 DOI: 10.1089/jwh.2023.0619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024] Open
Abstract
Objective: To examine racial/ethnic disparities in severe maternal morbidity (SMM) and adverse pregnancy outcomes (APOs) among pregnant patients with substance use disorder (SUD) compared to individuals without SUD. Materials and Methods: We conducted a cross-sectional analysis of inpatient hospitalizations of pregnant people from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) from 2016 to 2019. ICD-10 codes were used to identify the frequency of SMM and/or APO between those with and without SUD by race/ethnicity. Multilevel logistic regression analyses were performed to identify the effect of race/ethnicity as an independent predictor and as an effect modifier of SMM and APO in patients with SUD. Results: From 2,508,259 hospitalizations, SUD was identified in 6.7% admissions with the highest rate in White patients (8.2%) followed by Black (7.7%) and Hispanic (2.2%) patients. Rate of SMM and APO were increased in patients with SUD in all racial/ethnic groups compared to those without SUD, increasing by 1% and 10%, respectively. Among all patients, Black race was an independent predictor of SMM (adjusted odds ratio [aOR] 2.09; 95% confidence interval [CI]: 2.05-2.13) and APO (aOR 1.58; 95% CI: 1.56-1.59). Hispanic ethnicity was also an independent risk factor for predicting SMM (aOR 1.40; 95% CI: 1.37-1.43). Among Hispanic patients, SUD was associated with an ∼90% increased likelihood of SMM and APO. Conclusion: Although higher rates of SMM and APO are seen among hospitalizations of pregnant people with SUD, racial/ethnic disparities also exist among this population. This warrants further attention and presents an opportunity for intervention and for addressing the root causes of racial and ethnic disparities.
Collapse
Affiliation(s)
- Alexandra S Ragsdale
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Women's Health, Saint Louis University/SSM Health, St. Louis, Missouri, USA
| | - Noor Al-Hammadi
- Department of Health and Clinical Outcomes Research, Advanced HEAlth Data (AHEAD) Research Institute, Saint Louis University, St. Louis, Missouri, USA
| | - Sabel Bass
- Department of Epidemiology and Biostatistics, College of Public Health and Social Justice, Saint Louis University, St. Louis, Missouri, USA
| | - Niraj R Chavan
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Women's Health, Saint Louis University/SSM Health, St. Louis, Missouri, USA
| |
Collapse
|
14
|
Park M, Wanigaratne S, D'Souza R, Geoffrion R, Williams S, Muraca GM. Asian-White disparities in obstetric anal sphincter injury: a systematic review and meta-analysis. AJOG GLOBAL REPORTS 2024; 4:100296. [PMID: 38283323 PMCID: PMC10820309 DOI: 10.1016/j.xagr.2023.100296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024] Open
Abstract
OBJECTIVE Obstetrical anal sphincter injury describes a severe injury to the perineum and perianal muscles after birth. Obstetrical anal sphincter injury occurs in approximately 4.4% of vaginal births in the United States; however, racial and ethnic inequities in the incidence of obstetrical anal sphincter injury have been shown in several high-income countries. Specifically, an increased risk of obstetrical anal sphincter injury in individuals who identify as Asian vs those who identify as White has been documented among residents of the United States, Australia, Canada, Western Europe, and the Scandinavian countries. The high rates of obstetrical anal sphincter injury among the Asian diaspora in these countries are higher than obstetrical anal sphincter injury rates reported among Asian populations residing in Asia. A systematic review and meta-analysis of studies in high-income, non-Asian countries was conducted to further evaluate this relationship. DATA SOURCES MEDLINE, Ovid, Embase, EmCare, and the Cochrane databases were searched from inception to March 2023 for original research studies. STUDY ELIGIBILITY CRITERIA Observational studies using keywords and controlled vocabulary terms related to race, ethnicity and obstetrical anal sphincter injury. All observational studies, including cross-sectional, case-control, and cohort were included. 2 reviewers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Meta-analysis of Observational Studies in Epidemiology recommendations. METHODS Meta-analysis was performed using RevMan (version 5.4; Cochrane Collaboration, London, United Kingdom) for dichotomous data using the random effects model and the odds ratios as effect measures with 95% confidence intervals. Subgroup analysis was performed among Asian subgroups. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal tools. Meta-regression was used to determine sources of between-study heterogeneity. Results A total of 27 studies conducted in 7 countries met the inclusion criteria encompassing 2,337,803 individuals. The pooled incidence of obstetrical anal sphincter injury was higher among Asian individuals than White individuals (pooled odds ratio, 1.64; 95% confidence interval, 1.48-1.80). Subgroup analyses showed that obstetrical anal sphincter injury rates were highest among South Asians and among population-based vs hospital-based studies. Meta-regression showed that moderate heterogeneity remained even after accounting for differences in studies by types of Asian subgroups included, study year, mode of delivery included, and study setting. Conclusion Obstetrical anal sphincter injury is more frequent among Asian versus white birthing individuals in multiple high-income, non-Asian countries. Qualitative and quantitative research to elucidate underlying causal mechanisms responsible for this relationship are warranted.
Collapse
Affiliation(s)
- Meejin Park
- Faculty of Health Sciences, Department of Global Health, McMaster University, Hamilton, Ontario, Canada (Ms Park)
| | - Susitha Wanigaratne
- Edwin S.H. Leong Centre for Healthy Children, SickKids Research Institute, Toronto, Ontario, Canada (Dr Wanigaratne)
| | - Rohan D'Souza
- Faculty of Health Sciences, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Drs D'Souza and Muraca)
- Faculty of Health Sciences, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada (Drs D'Souza and Muraca)
| | - Roxana Geoffrion
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (Dr Geoffrion)
| | - Sarah Williams
- Department of Anthropology, University of Connecticut, Mansfield, CT (Dr Williams)
| | - Giulia M. Muraca
- Faculty of Health Sciences, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Drs D'Souza and Muraca)
- Faculty of Health Sciences, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada (Drs D'Souza and Muraca)
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden (Dr Muraca)
| |
Collapse
|
15
|
Kern-Goldberger AR, Madden N, Baptiste C, Friedman A, Gyamfi-Bannerman C. Maternal and Neonatal Morbidities by Race in College-Educated Women. AJP Rep 2024; 14:e57-e61. [PMID: 38288160 PMCID: PMC10824592 DOI: 10.1055/s-0043-1778000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/22/2023] [Indexed: 01/31/2024] Open
Abstract
Objective Non-Hispanic black and Hispanic women experience significantly higher adverse maternal and neonatal outcomes compared with non-Hispanic white women. The purpose of this study is to explore whether disparities in obstetric outcomes exist by race among women who are college-educated. Study Design This is a retrospective cohort study from a multicenter observational cohort of women undergoing cesarean delivery. Women were defined as "college-educated" if they reported completion of a 4-year college degree. Race/ethnicity was categorized as non-Hispanic white, non-Hispanic black, Hispanic, Asian, Native American, or unknown. The primary outcome was a composite of maternal morbidity, and a composite of neonatal morbidity was evaluated as a secondary outcome. A multivariable logistic regression model was then utilized to assess associations of race with the primary and secondary outcomes. Results A total of 2,540 women were included in the study. After adjusting for potential confounding variables, maternal morbidity was found to be significantly higher for college-educated non-Hispanic black women compared with non-Hispanic white women (odds ratio [OR] 1.77, 95% confidence interval [CI] 1.12-2.80). The incidence of neonatal morbidity was significantly higher for non-Hispanic black (OR 1.91, 95% CI 1.31-2.79) and Hispanic (OR 3.34, 95% CI 2.23-5.01) women. Conclusion In this cohort, the odds of cesarean-related maternal and neonatal morbidities were significantly higher for college-educated non-Hispanic black women, compared with their non-Hispanic white counterparts. This demonstrates that even among women with higher level education, racial and ethnic disparities persist in obstetric outcomes.
Collapse
Affiliation(s)
- Adina R. Kern-Goldberger
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
| | - Nigel Madden
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
| | - Caitlin Baptiste
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
- Division of Maternal-Fetal Medicine, Columbia University Irving Medical Center, New York, New York
| | - Alexander Friedman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
- Division of Maternal-Fetal Medicine, Columbia University Irving Medical Center, New York, New York
| | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
- Division of Maternal-Fetal Medicine, Columbia University Irving Medical Center, New York, New York
| |
Collapse
|
16
|
Teal EN, Anudokem K, Baer RJ, Jelliffe-Pawlowski L, Mengesha B. Racial Disparities in the Rates of and Indications for Cesarean Delivery in California: Are They Changing Over Time? Am J Perinatol 2024; 41:31-38. [PMID: 34856615 DOI: 10.1055/s-0041-1740071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The aim of this study was to assess whether racial disparities in rates of and indications for cesarean delivery (CD) between non-Hispanic Black and non-Hispanic White birthing people in California changed from 2011 to 2017. METHODS This was a retrospective cohort study using a database of birth certificates linked to discharge records. Singleton term live births in nulliparous Black and White birthing people in California between 2011 and 2017 were included. Those with noncephalic presentation, placenta previa, and placenta accreta were excluded. CD rate and indication were obtained from birth certificate variables and International Classification of Diseases codes. Differences in CD rate and indication were calculated for Black versus White individuals using univariable and multivariable logistic regression and adjusted for potential confounders. RESULTS A total of 348,144 birthing people were included, 46,361 Black and 301,783 White. Overall, 30.9% of Black birthing people underwent CD compared with 25.3% of White (adjusted relative risk [aRR]: 1.2, 95% confidence interval [CI]: 1.2-1.3). From 2011 to 2017, the CD rate fell 11% (26.4-23.7%, p < 0.0001) for White birthing people and 1% for Black birthing people (30.4-30.1%, p = 0.037). Over the study period, Black birthing people had a persistent 1.2- to 1.3-fold higher risk of CD and were persistently more likely to undergo CD for fetal intolerance (aRR: 1.1, 95% CI: 1.1-1.2) and less likely for active phase arrest or arrest of descent (aRRs: 0.9 and 0.4; 95% CIs: 0.9-0.9 and 0.3-0.5). CONCLUSION The CD rate decreased substantially for White birthing people and minimally for Black birthing people in our cohort over the study period. Meanwhile, disparities in CD rate and indications between the two groups persisted, despite controlling for confounders. Although care bundles for reducing CD may be effective among White birthing people, they are not associated with reduction in CD rates among Black birthing people nor improvements in racial disparities between Black and White birthing people. PRECIS Despite increasing attention to racial inequities in obstetric outcomes, there were no changes in disparities in CD rates or indications in California from 2011 to 2017. KEY POINTS · Black birthing people are more likely to undergo CD than White despite controlling for confounders.. · There are unexplained differences in CD indication among Black and White birthing people.. · These disparities persisted from 2011 to 2017 despite increasing efforts to decrease CD rates in CA..
Collapse
Affiliation(s)
- E Nicole Teal
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, North Carolina
| | - Kelechi Anudokem
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | - Rebecca J Baer
- California Preterm Birth Initiative, University of California, San Francisco, San Francisco, California
| | - Laura Jelliffe-Pawlowski
- California Preterm Birth Initiative, University of California, San Francisco, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Biftu Mengesha
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| |
Collapse
|
17
|
Wadsworth P, Graves L, Pogula M, Duerst A, Southard J, Kothari C, Presberry J. Patients' Perspectives on Informational Support and Education in the Perinatal Period: "The Quicker They Could Be Done With Me, the Better". J Midwifery Womens Health 2024; 69:110-117. [PMID: 37486773 DOI: 10.1111/jmwh.13548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/24/2023] [Indexed: 07/26/2023]
Abstract
INTRODUCTION The overall purpose of this study was to elicit perspectives from a diverse group of postpartum individuals about their perinatal outpatient informational support and education. In addition, suggestions from participants are provided. Although informational support is crucial in the peripartum period, it is often inadequate or biased. Qualitative research, which offers a nuanced and patient-centered perspective, is limited. The qualitive research that does exist is limited to the prenatal period only, neglecting perspectives throughout the entire peripartum period. METHODS This qualitative descriptive study was part of a larger observational cross-sectional study of postpartum individuals in Kalamazoo, Michigan in 2017. Two years after the initial study (2019), participants were recruited into 8 focus groups. Trained facilitators guided focus group conversations using semistructured interview questions. The questions centered on overall experiences with perinatal outpatient health care experiences and informational support. Thematic analyses were used in data analysis. Interrater reliability between coders ranged from 92% to 100%. RESULTS Fifty-four individuals (22.1% response rate) participated in a total of 12 focus groups. The overarching theme was the need for recognition of individuality of patients. Three subthemes emerged, including time, multiple modalities of information support, and agency. DISCUSSION This study extended previous qualitative findings across the entire peripartum period and that individualized prenatal care is an important distinction in perceived quality of care. Health care organizations should consider allocating time differently for perinatal office visits, offer flexible visit times based on individualized needs, offer information in multiple modalities, and promote agency of patients. This study was strengthened by the community involvement, women of color only focus groups, and oversampling of Black women. This study was limited by the self-selected, homogenous sample and potential for recall bias.
Collapse
Affiliation(s)
- Pamela Wadsworth
- Bronson School of Nursing, Western Michigan University, Kalamazoo, Michigan
| | - Lisa Graves
- Department of Family and Community Medicine, Western Michigan University Medical School, Kalamazoo, Michigan
| | - Mounika Pogula
- Western Michigan University Medical School, Kalamazoo, Michigan
| | - Abby Duerst
- Western Michigan University Medical School, Kalamazoo, Michigan
| | - James Southard
- Western Michigan University Medical School, Kalamazoo, Michigan
| | - Catherine Kothari
- Department of Biomedical Sciences, Western Michigan University Medical School, Kalamazoo, Michigan
| | - Joi Presberry
- Western Michigan University Medical School, Kalamazoo, Michigan
| |
Collapse
|
18
|
Chatterji P, Glenn H, Markowitz S, Montez JK. Affordable Care Act Medicaid expansions and maternal morbidity. HEALTH ECONOMICS 2023; 32:2334-2352. [PMID: 37417880 PMCID: PMC10691745 DOI: 10.1002/hec.4724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 05/18/2023] [Accepted: 06/06/2023] [Indexed: 07/08/2023]
Abstract
In this paper, we test whether the Affordable Care Act Medicaid expansions are associated with maternal morbidity. The ACA expansions may have affected maternal morbidity by increasing pre-conception access to health care, and by improving the quality of delivery care, through enhancing hospitals' financial positions. We use difference-in-difference models in conjunction with event studies. Data come from individual-level birth certificates and state-level hospital discharge data. The results show little evidence that the expansions are associated with overall maternal morbidity or indicators of specific adverse events including eclampsia, ruptured uterus, and unplanned hysterectomy. The results are consistent with prior research showing that the ACA Medicaid expansions are not statistically associated with pre-pregnancy health or maternal health during pregnancy. Our results add to this story and find little evidence of improvements in maternal health upon delivery.
Collapse
|
19
|
Heyrana KJ, Kaneshiro B, Soon R, Nguyen BT, Natavio MF. Data Equity for Asian American and Native Hawaiian and Other Pacific Islander People in Reproductive Health Research. Obstet Gynecol 2023; 142:787-794. [PMID: 37678914 PMCID: PMC10510826 DOI: 10.1097/aog.0000000000005340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/15/2023] [Accepted: 05/25/2023] [Indexed: 09/09/2023]
Abstract
Though racial and ethnic disparities in sexual and reproductive health outcomes are receiving greater interest and research funding, the experiences of Asian American and Native Hawaiian and Other Pacific Islander (NHPI) people are often combined with those of other racial and ethnic minority groups or excluded from data collection altogether. Such treatment is often rationalized because Asian American and NHPI groups comprise a smaller demographic proportion than other racial or ethnic groups, and the model minority stereotype assumes that these groups have minimal sexual and reproductive health needs. However, Asian American and NHPI people represent the fastest-growing racial-ethnic groups in the United States, and they face disparities in sexual and reproductive health access, quality of care, and outcomes compared with those of other races and ethnicities. Disaggregating further by ethnicity, people from certain Asian American and NHPI subgroups face disproportionately poor reproductive health outcomes that suggest the need for culturally targeted exploration of the unique drivers of these inequities. This commentary highlights the evidence for sexual and reproductive health disparities both in and between Asian American and NHPI groups. We also examine the failures of national data sets and clinical studies to recruit Asian American and NHPI people in proportion to their share of the U.S. population or to consider how the cultural and experiential diversity of Asian American and NHPI people influence sexual and reproductive health. Lastly, we provide recommendations for the equitable inclusion of Asian American and NHPI people to promote and systematize the study and reporting of sexual and reproductive health behaviors and outcomes in these culturally, religiously, and historically diverse groups.
Collapse
Affiliation(s)
- Katrina J Heyrana
- Department of Obstetrics & Gynecology, Cedars Sinai Medical Center, and the Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California; and the Department of Obstetrics, Gynecology & Women's Health, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | | | | | | | | |
Collapse
|
20
|
Kern-Goldberger AR, Booker W, Friedman A, Gyamfi-Bannerman C. Racial and Ethnic Disparities in Cesarean Morbidity. Am J Perinatol 2023; 40:1567-1572. [PMID: 34891196 DOI: 10.1055/s-0041-1739305] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Maternal race and ethnicity have been identified as significant independent predictors of obstetric morbidity and mortality in the United States. An appreciation of the clinical contexts in which maternal racial and ethnic disparities are most pronounced can better target efforts to alleviate these disparities and improve outcomes. It remains unknown whether cesarean delivery precipitates these divergent outcomes. This study assessed the association between maternal race and ethnicity and cesarean complications. STUDY DESIGN We conducted a retrospective cohort study from a multicenter observational cohort of women undergoing cesarean delivery. Nulliparous women with non-anomalous singleton gestations who underwent primary cesarean section were included. Race/ethnicity was categorized as non-Hispanic White, non-Hispanic Black, Hispanic, Asian, Native American, or unknown. The primary outcome was a composite of maternal cesarean complications including hysterectomy, uterine atony, blood transfusion, surgical injury, arterial ligation, infection, wound complication, and ileus. A composite of neonatal morbidity was evaluated as a secondary outcome. We created a multivariable logistic regression model adjusting for selected demographic and obstetric variables that may influence the likelihood of the primary outcome. RESULTS A total of 14,570 women in the parent trial met inclusion criteria with an 18.8% incidence of the primary outcome (2,742 women). After adjusting for potential confounding variables, maternal surgical morbidity was found to be significantly higher for non-Hispanic Black (adjusted odds ratios [aORs] 1.96, 95% confidence intervals [CIs] 1.63-2.35) and Hispanic (aOR 1.66, 95% CI 1.37-2.01) women as compared with non-Hispanic white women. Neonatal morbidity was similarly found to be significantly associated with the Black race and Hispanic ethnicity. CONCLUSION In this cohort, the odds of cesarean-related maternal and neonatal morbidity were significantly higher for non-Hispanic Black and Hispanic women. These findings suggest race as a distinct risk factor for cesarean complications, and efforts to alleviate disparities should highlight cesarean section as an opportunity for improvement in outcomes. KEY POINTS · Non-Hispanic Black and Hispanic women experienced more cesarean complications than non-Hispanic White women.. · These findings suggest that disparities in maternal and neonatal outcomes exist specifically following cesarean section.. · Efforts to alleviate disparities in obstetrics should highlight cesarean section as an opportunity for improvement..
Collapse
Affiliation(s)
- Adina R Kern-Goldberger
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
| | - Whitney Booker
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
- Division of Maternal-Fetal Medicine, Columbia University Irving Medical Center, New York, New York
| | - Alexander Friedman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
- Division of Maternal-Fetal Medicine, Columbia University Irving Medical Center, New York, New York
| | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
- Division of Maternal-Fetal Medicine, Columbia University Irving Medical Center, New York, New York
| |
Collapse
|
21
|
Holt EW, Murarka SM, Zhao Z, Baker MV, Omosigho UR, Adam RA. Investigating disparities in compliance of nursing pain reassessment for obstetrics and gynecology patients. Am J Obstet Gynecol 2023; 229:314.e1-314.e11. [PMID: 37330130 PMCID: PMC10268944 DOI: 10.1016/j.ajog.2023.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 05/13/2023] [Accepted: 06/09/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Racial and socioeconomic disparities, exacerbated during the COVID-19 pandemic and surrounding socio-political polarization, affect access to, delivery of, and patient perception of healthcare. Perioperatively, the bedside nurse carries the greatest responsibility of direct care, which includes pain reassessment, a metric tracked for compliance. OBJECTIVE This study aimed to critically assess disparities in obstetrics and gynecology perioperative care and how these have changed since March 2020 using nursing pain reassessment compliance within a quality improvement framework. STUDY DESIGN A retrospective cohort of 76,984 pain reassessment encounters from 10,774 obstetrics and gynecology patients at a large, academic hospital from September 2017 to March 2021 was obtained from Tableau: Quality, Safety and Risk Prevention platform. Noncompliance proportions were analyzed by patient race across service lines; a sensitivity analysis was performed excluding patients who were of neither Black nor White race. Secondary outcomes included analysis by patient ethnicity, body mass index, age, language, procedure, and insurance. Additional analyses were performed by temporally stratifying patients into pre- and post-March 2020 cohorts to investigate potential pandemic and sociopolitical effects on healthcare disparities. Continuous variables were assessed with Wilcoxon rank test, categorical variables were assessed with chi-squared test, and multivariable logistic regression analyses were performed (P<.05). RESULTS Noncompliance proportions of pain reassessment did not differ significantly between Black and White patients as an aggregate of all obstetrics and gynecology patients (8.1% vs 8.2%), but greater differences were found within the divisions of Benign Subspecialty Gynecologic Surgery (Minimally Invasive Gynecologic Surgery + Urogynecology) (14.9% vs 10.70%; P=.03) and Maternal Fetal Medicine (9.5% vs 8.3%; P=.04). Black patients admitted to Gynecologic Oncology experienced lower noncompliance proportions than White patients (5.6% vs 10.4%; P<.01). These differences persisted after adjustment for body mass index, age, insurance, timeline, procedure type, and number of nurses attending to each patient with multivariable analyses. Noncompliance proportions were higher for patients with body mass index ≥35 kg/m2 within Benign Subspecialty Gynecology (17.9% vs 10.4%; P<.01). Non-Hispanic/Latino patients (P=.03), those ≥65 years (P<.01), those with Medicare (P<.01), and those who underwent hysterectomy (P<.01) also experienced greater noncompliance proportions. Aggregate noncompliance proportions differed slightly pre- and post-March 2020; this trend was seen across all service lines except Midwifery and was significant for Benign Subspecialty Gynecology after multivariable analysis (odds ratio, 1.41; 95% confidence interval, 1.02-1.93; P=.04). Though increases in noncompliance proportions were seen for non-White patients after March 2020, this was not statistically significant. CONCLUSION Significant race, ethnicity, age, procedure, and body mass index-based disparities were identified in the delivery of perioperative bedside care, especially for those admitted to Benign Subspecialty Gynecologic Services. Conversely, Black patients admitted to Gynecologic Oncology experienced lower levels of nursing noncompliance. This may be in part be related to the actions of a Gynecologic Oncology nurse practioner at our institution who helps coordinate care for the division's postoperative patients. Noncompliance proportions increased after March 2020 within Benign Subspecialty Gynecologic Services. Although this study was not designed to establish causation, possible contributing factors include implicit or explicit biases regarding pain experience across race, body mass index, age, or surgical indication, discrepancies in pain management across hospital units, and downstream effects of healthcare worker burnout, understaffing, increased use of travelers, or sociopolitical polarization since March 2020. This study demonstrates the need for ongoing investigation of healthcare disparities at all interfaces of patient care and provides a way forward for tangible improvement of patient-directed outcomes by utilizing an actionable metric within a quality improvement framework.
Collapse
Affiliation(s)
- Edwin W Holt
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN.
| | - Shivani M Murarka
- Division of Female Pelvic Medicine and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Zhiguo Zhao
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Mary V Baker
- Division of Female Pelvic Medicine and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Ukpebo R Omosigho
- Division of Female Pelvic Medicine and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Rony A Adam
- Division of Female Pelvic Medicine and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
22
|
Rattan J, Bartlett TR. Potential influence of nurses' implicit racial bias on maternal mortality. Public Health Nurs 2023; 40:773-781. [PMID: 37141152 PMCID: PMC10775957 DOI: 10.1111/phn.13201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 04/08/2023] [Accepted: 04/11/2023] [Indexed: 05/05/2023]
Abstract
Stark disparities persist in maternal mortality and perinatal outcomes for Black and other birthing people of color, such as Native Americans, and their newborns compared to White people in the United States. An increasing body of research describes the phenomenon of implicit racial bias among providers and how it may affect communication, treatment decisions, the patient care experience, and health outcomes. This synthesis of literature reviews and distills current research on the presence and influence of implicit racial bias among nurses as it may relate to maternal and pregnancy-related care and outcomes. In this paper, we also summarize what is known about implicit racial bias among other types of healthcare providers and interventions that can mitigate its effects, identify a gap in research, and recommend next steps for nurses and nurse researchers.
Collapse
Affiliation(s)
- Jesse Rattan
- Joint Nursing Science PhD Program, The University of Alabama and University of Alabama in Huntsville, Tuscaloosa
| | | |
Collapse
|
23
|
Boulos NM, Burton BN, Hernandez-Morgan ME. Demographic and Socioeconomic Disparities in Maternal Health Care. Anesth Analg 2023; 137:e16-e17. [PMID: 37450917 DOI: 10.1213/ane.0000000000006567] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Affiliation(s)
- Nancy M Boulos
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington,
| | - Brittany N Burton
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, California
| | - Marisa E Hernandez-Morgan
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, California
| |
Collapse
|
24
|
Fuller S, Kuenstler M, Snipes M, Miller M, Lutgendorf MA. Obstetrical health care inequities in a universally insured health care system. AJOG GLOBAL REPORTS 2023; 3:100256. [PMID: 37638226 PMCID: PMC10458343 DOI: 10.1016/j.xagr.2023.100256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND Racial and ethnic disparities in health care exist and are rooted in long-standing systemic inequities. These disparities result in significant excess health care expenditures and are due to complex interactions between patients, health care providers and systems, and social and environmental factors. In perinatal care, these inequities also exist, with Black patients being 3 to 4 times more likely to die of childbirth compared with White patients. Similar health care inequities may also exist in the Military Health System despite universal health care coverage, stable employment, and social programs that benefit military families. OBJECTIVE This study aimed to evaluate racial disparities in obstetrical outcomes in the Military Health System. STUDY DESIGN This is a retrospective cohort study of deliveries from 2019 to 2021 in the Military Health System, which provides obstetrical care for approximately 35,000 annual deliveries. The study was conducted using National Perinatal Information Center data on cesarean delivery, postpartum hemorrhage, and severe maternal morbidity by race and ethnicity from direct-care military hospitals representing tertiary care medical centers and community hospitals in the United States and abroad. Chi-square analyses and binary logistic regression were used to compare groups. RESULTS The cohort included 68,918 deliveries. Of these, 32,358 (47%) were White, 9594 (13.9%) Black, 3120 (4.5%) Asian Pacific Islander, 456 (0.7%) American Indian/Alaska Native, 19,543 (28.4%) other, 3976 (5.8%) unknown, 7096 (10.3%) Hispanic, 58,009 (84.2%) non-Hispanic, and 4399 (6.4%) other ethnicity. Rates of cesarean delivery were significantly higher for Black (30%; odds ratio, 1.44; 95% confidence interval, 1.37-1.52), Asian Pacific Islander (27%; odds ratio, 1.24; 95% confidence interval, 1.14-1.35), and other (26%; odds ratio, 1.20; 95% confidence interval, 1.15-1.25) compared with White race (23%) (P<.001). Postpartum hemorrhage rates were higher for Black (5.9%; odds ratio, 1.11; 95% confidence interval, 1.00-1.24) and Asian Pacific Islander (7.7%; odds ratio, 1.49; 95% confidence interval, 1.29-1.72) compared with White race (5.3%) (P<.001). Severe maternal morbidity was higher for Black (2.9%; odds ratio, 1.44; 95% confidence interval, 1.24-1.67), Asian Pacific Islander (2.9%; odds ratio, 1.45; 95% confidence interval, 1.15-1.82), and other (2.8%; odds ratio, 1.36; 95% confidence interval, 1.21-1.54) compared with White race (2.1%) (P<.001). For severe maternal morbidity excluding blood transfusions, rates were also significantly higher for Black (1%; odds ratio, 1.68; 95% confidence interval, 1.30-2.17) than for White race (0.6%) (P<.002). Hispanic ethnicity was associated with a lower rate of severe maternal morbidity excluding transfusions (0.5%; odds ratio, 0.68; 95% confidence interval, 0.48-0.98) compared with non-Hispanic ethnicity (0.7%) (P=.04). CONCLUSION Racial disparities in obstetrical outcomes exist in the Military Health System despite universal health care coverage, with significantly higher rates of cesarean delivery and severe maternal morbidity in Black, Asian Pacific Islander, and other races compared with White race. These findings suggest that these disparities are likely related to other factors or social determinants of health rather than availability of health care and insurance coverage. Further work should include investigation into such social determinants of health to address their causes, including systemic and structural barriers.
Collapse
Affiliation(s)
- Shara Fuller
- Department of Gynecologic Surgery and Obstetrics, Naval Medical Center San Diego, San Diego, CA (Drs Fuller and Miller)
| | - Molly Kuenstler
- Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Bethesda, MD (Dr Kuenstler and Dr Lutgendorf)
| | - Marie Snipes
- Department of Mathematics and Statistics, Kenyon College, Gambier, OH (Dr Snipes)
| | - Michael Miller
- Department of Gynecologic Surgery and Obstetrics, Naval Medical Center San Diego, San Diego, CA (Drs Fuller and Miller)
| | - Monica A. Lutgendorf
- Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Bethesda, MD (Dr Kuenstler and Dr Lutgendorf)
| |
Collapse
|
25
|
Patek K, Friedman P. Postpartum Hemorrhage-Epidemiology, Risk Factors, and Causes. Clin Obstet Gynecol 2023; 66:344-356. [PMID: 37130373 DOI: 10.1097/grf.0000000000000782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
The incidence of postpartum hemorrhage (PPH) is increasing worldwide and in the United States. Coinciding, is the increased rate of severe maternal morbidity with blood transfusion in the United States over the past 2 decades. Consequences of PPH can be life-threatening and carry significant cost burden to the health care system. This review will discuss the current trends, distribution, and risk factors for PPH. Causes of PPH will be explored in detail.
Collapse
Affiliation(s)
- Kara Patek
- Corewell Health William Beaumont University Hospital, Royal Oak, Michigan
| | | |
Collapse
|
26
|
DiTosto JD, Roytman MV, Dolan BM, Khan SS, Niznik CM, Yee LM. Improving Postpartum and Long-Term Health After an Adverse Pregnancy Outcome: Examining Interventions From a Health Equity Perspective. Clin Obstet Gynecol 2023; 66:132-149. [PMID: 36657050 PMCID: PMC9869461 DOI: 10.1097/grf.0000000000000759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Gestational diabetes mellitus and hypertensive disorders in pregnancy are adverse pregnancy outcomes (APOs) that affect 15% of pregnancies in the United States. These APOs have long-term health implications, with greater risks of future cardiovascular and chronic disease later in life. In this manuscript, we review the importance of timely postpartum follow-up and transition to primary care after APOs for future disease prevention. We also discuss interventions to improve postpartum follow-up and long-term health after an APO. In recognizing racial and ethnic disparities in APOs and chronic disease, we review important considerations of these interventions through a health equity lens.
Collapse
Affiliation(s)
- Julia D. DiTosto
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Maya V. Roytman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
- Loyola University Chicago, Chicago, IL
| | - Brigid M. Dolan
- Division of General Internal Medicine, Departments of Medicine and Medical Education, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sadiya S. Khan
- Division of Cardiology, Departments of Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Charlotte M. Niznik
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lynn M. Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| |
Collapse
|
27
|
DiPietro Mager NA, Zollinger TW, Turman JE, Zhang J, Dixon BE. Preconception health status and associated disparities among rural, Midwestern women in the United States. Birth 2023; 50:127-137. [PMID: 36696365 DOI: 10.1111/birt.12706] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/09/2020] [Accepted: 12/15/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Little is known about the preconception/interconception health and behaviors of reproductive-age women in the rural Midwest of the United States. The purpose of this study was to quantify preconception/interconception health status and to identify disparities compared with statewide estimates. METHODS In this cross-sectional study, we collected data on 12 health conditions and behaviors that are risk factors for adverse maternal and infant health outcomes from nonpregnant women ages 18-45 years in rural northwestern Ohio. Statistical tests were used to identify associations between selected demographic characteristics and a subset of eight high-priority health measures (smoking, diabetes, heavy alcohol use, folic acid intake, normal weight, sufficient physical activity, and effective contraception use); all but physical activity could be compared with Ohio estimates derived from the Behavioral Risk Factor Surveillance System and Ohio Pregnancy Assessment Survey. RESULTS Three hundred-fifteen women participated, with 98.4% reporting at least one high-priority risk factor. Statistically significant differences were identified among subpopulations related to smoking, folic acid, normal weight, sufficient physical activity, and effective contraception use. In addition, the proportion of participants reporting hypertension (P < 0.001), smoking (P < 0.001), abnormal weight (P = 0.002), and lack of daily folic acid intake (P = 0.006) were statistically significantly higher than expected based on statewide estimates. CONCLUSIONS Women in the rural Midwest of the United States are at risk for poor health and pregnancy outcomes. Statewide estimates tracking preconception/interconception health status may obscure variation for at-risk groups, particularly in rural or underserved areas. These findings illustrate the need for interventions to advance preconception/interconception health and improve methods to capture and analyze data for rural women.
Collapse
Affiliation(s)
- Natalie A DiPietro Mager
- Department of Epidemiology, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA
| | - Terrell W Zollinger
- Department of Epidemiology, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA
| | - Jack E Turman
- Department of Social and Behavioral Sciences, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jianjun Zhang
- Department of Epidemiology, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA.,Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, Indiana, USA
| | - Brian E Dixon
- Department of Epidemiology, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA.,Center for Biomedical Informatics, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| |
Collapse
|
28
|
Asim S, Nichini E, Goggins WB, Dong D, Yeoh EK. Maternity care experience of Pakistani ethnic minority women in Hong Kong. Front Public Health 2023; 11:1009214. [PMID: 36935720 PMCID: PMC10014597 DOI: 10.3389/fpubh.2023.1009214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 02/07/2023] [Indexed: 03/06/2023] Open
Abstract
Background Persistent inequalities in maternity care experience and outcomes exist globally for ethnic minority (EM) and migrant women. Despite the fact that this is an important research area, no prior study has been done in Hong Kong (HK) to examine maternity care experience of EM women. Objectives To investigate maternity care experience of Pakistani EM women (both local born and immigrants) during pregnancy, birth and after birth in hospital in HK. An evaluation of their satisfaction and factors predicting satisfaction with care during the three phases of maternity care was included in the study. Methods A cross sectional survey was conducted among Pakistani EM women who had given birth in HK in last 3 years, using a structured questionnaire by a bilingual interviewer, from April to May 2020. Counts and percentages were used to describe all categorical variables. Association between predictor variables and overall satisfaction was assessed by bivariate analysis and multiple logistic regression. Results One hundred and twenty questionnaires were completed. Almost 60 percent of the women were very satisfied with the overall care. More than half of the women described the care they received as kind, respectful and well communicated. After adjusting for age and parity, HK born Pakistani women expressed relatively less satisfaction with care, especially during pregnancy and labor and birth, as compared with Pakistan born women. Women with conversational or fluent English-speaking ability also felt comparatively less satisfied particularly from intrapartum and postnatal care in hospital. Education level had a negative association with satisfaction with care during pregnancy. Conclusions Maternity care providers should take into account the diversity of EM women population in HK. Our findings suggest that effective communication and care that can meet individual needs, expectations, and values is imperative to improve experience and quality of maternity care for EM women in HK.
Collapse
Affiliation(s)
- Saba Asim
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Elena Nichini
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - William Bernard Goggins
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Dong Dong
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- Centre for Health Systems and Policy Research, JC School of Public Health and Primary Care, Hong Kong, Hong Kong SAR, China
- *Correspondence: Dong Dong
| | - Eng-King Yeoh
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- Centre for Health Systems and Policy Research, JC School of Public Health and Primary Care, Hong Kong, Hong Kong SAR, China
| |
Collapse
|
29
|
Poehlmann JR, Avery G, Antony KM, Broman AT, Godecker A, Green TL. Racial disparities in post-operative pain experience and treatment following cesarean birth. J Matern Fetal Neonatal Med 2022; 35:10305-10313. [PMID: 36195464 DOI: 10.1080/14767058.2022.2124368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To evaluate racial/ethnic differences in post-operative pain experience and opioid medication use (morphine milligram equivalent) in the first 24 h following cesarean birth. METHODS This study was a single-center retrospective cohort of birthing persons who underwent cesarean deliveries between 1/1/16 and 12/31/17. A total of 2,228 cesarean deliveries were analyzed. The primary outcome was average pain, which was the mean of all documented self-reported pain scores (0-10 scale) during the first 24 h post-delivery. The secondary outcome included oral morphine equivalents used in the first 24 h post-delivery. Linear regression was performed to examine whether the race/ethnicity of the birthing parent was associated with mean pain scores and oral morphine equivalents, controlling for confounding variables. RESULTS In multivariate analyses non-Hispanic Black birthing persons reported higher mean pain scores (Coefficient: 0.61, 95% confidence interval [0.39-0.82], p < .001]) than non-Hispanic White birthing persons, but received similar quantities of morphine milligram equivalent (Coefficient: -0.98 mg, 95% confidence interval [-5.93-3.97], p = .698]). Non-Hispanic Asian birthing persons reported similar reported mean pain scores to those of non-Hispanic White birthing persons (Coefficient: 0.02 mg, 95% confidence interval [-0.17-0.22], p = .834]), but received less morphine milligram equivalent (Coefficient: -5.47 mg, 95% confidence interval [-10.05 to -0.90], p = .019). When controlling for reported mean pain scores, both non-Hispanic Black (Coefficient: -6.36 mg, 95% confidence interval [-10.97 to -1.75], p = .007) and non-Hispanic Asian birthing persons (Coefficient: -5.66 mg, 95% confidence interval [-9.89 to -1.43], p = .009) received significantly less morphine milligram equivalents. CONCLUSION Despite reporting higher mean pain scores, non-Hispanic Black birthing persons did not receive higher quantities of morphine milligram equivalent. Non-Hispanic Asian birthing persons received lower quantities of morphine milligram equivalent despite reporting similar pain scores to non-Hispanic White birthing persons. These differences suggest disparities in post-operative pain management for birthing persons of color in our study population.
Collapse
Affiliation(s)
- John R Poehlmann
- Department of Obstetrics & Gynecology, University of Wisconsin-Madison, Madison, WI, USA
| | - Gabrielle Avery
- Department of Obstetrics & Gynecology, University of Wisconsin-Madison, Madison, WI, USA
| | - Kathleen M Antony
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Aimee Teo Broman
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA
| | - Amy Godecker
- Department of Obstetrics & Gynecology, University of Wisconsin-Madison, Madison, WI, USA
| | - Tiffany L Green
- Departments of Population Health Sciences and Obstetrics & Gynecology, University of Wisconsin-Madison, Madison, WI, USA
| |
Collapse
|
30
|
Hosier H, Xu X, Underwood K, Ackerman-Banks C, Campbell KH, Reddy UM. Racial and ethnic differences in severe maternal morbidity among singleton stillbirth deliveries. Am J Obstet Gynecol MFM 2022; 4:100708. [PMID: 35964935 DOI: 10.1016/j.ajogmf.2022.100708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/22/2022] [Accepted: 08/08/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite growing evidence suggesting racial or ethnic disparities in the risk of severe maternal morbidity among live births, there is little research investigating potential differences in severe maternal morbidity risk among stillbirths across race and ethnicity. OBJECTIVE This study aimed to compare the risk of severe maternal morbidity by race and ethnicity among patients with singleton stillbirth pregnancies. STUDY DESIGN We used the California Linked Birth File database to perform a retrospective analysis of singleton stillbirth pregnancies delivered at 20 to 42 weeks' gestation between 2007 and 2011. The database contained information from fetal death certificates linked to maternal hospital discharge records. We defined severe maternal morbidity using the Centers for Disease Control and Prevention composite severe maternal morbidity indicator and compared rates of severe maternal morbidity across racial and ethnic groups. Multivariable regression analysis was used to examine how race and ethnicity were associated with severe maternal morbidity risk after accounting for the influence of patients' clinical risk factors, socioeconomic characteristics, and attributes of the delivery hospital. RESULTS Of the 9198 patients with singleton stillbirths, 533 (5.8%) experienced severe maternal morbidity. Non-Hispanic Black patients had a significantly higher risk of severe maternal morbidity (10.6% vs 5.2% in non-Hispanic White patients, 5.2% in Hispanic patients, and 5.1% in patients with other race or ethnicity; P<.001). The higher risk of severe maternal morbidity among non-Hispanic Black patients persisted even after adjusting for patients' clinical, socioeconomic, and hospital characteristics (adjusted odds ratio for non-Hispanic Black vs non-Hispanic White patients, 1.74; 95% confidence interval, 1.21-2.50). Further analysis separating blood-transfusion and nontransfusion severe maternal morbidity showed a higher risk of blood transfusion in non-Hispanic Black patients, which remained significant after adjusting for patients' clinical, socioeconomic, and hospital characteristics (adjusted odds ratio for non-Hispanic Black vs non-Hispanic White patients, 1.64; 95% confidence interval, 1.11-2.43). However, the higher risk of nontransfusion severe maternal morbidity in non-Hispanic Black patients was no longer significant after adjusting for patients' clinical risk factors (adjusted odds ratio for non-Hispanic Black vs non-Hispanic White patients, 1.38; 95% confidence interval, 0.83-2.30). CONCLUSION Severe maternal morbidity occurred in 5.8% of patients with a singleton stillbirth. Risk of severe maternal morbidity in stillbirth was higher in patients with non-Hispanic Black race, which was likely owing to a higher risk of hemorrhage, as evidenced by increased rate of blood transfusion.
Collapse
Affiliation(s)
- Hillary Hosier
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT.
| | - Xiao Xu
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Katherine Underwood
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Christina Ackerman-Banks
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Katherine H Campbell
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Uma M Reddy
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| |
Collapse
|
31
|
Fishel Bartal M, Chen HY, Mendez-Figueroa H, Wagner SM, Chauhan SSP. Racial and Ethnic Disparities in Primary Cesarean Birth and Adverse Outcomes Among Low-Risk Nulliparous People. Obstet Gynecol 2022; 140:842-852. [PMID: 36201767 PMCID: PMC10069716 DOI: 10.1097/aog.0000000000004953] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/21/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To compare trend of primary cesarean delivery rate and composite neonatal and maternal adverse outcomes in low-risk pregnancies among racial and ethnic groups: non-Hispanic White, non-Hispanic Black, and Hispanic. METHODS This population-based cohort study used U.S. vital statistics data (2015-2019) to evaluate low-risk, nulliparous patients with nonanomalous singletons who labored and delivered at 37-41 weeks of gestation. The primary outcome was the primary cesarean delivery rate. Secondary outcomes included composite neonatal adverse outcome (Apgar score less than 5 at 5 minutes, assisted ventilation for more than 6 hours, seizure, or death), and composite maternal adverse outcome (intensive care unit admission, blood transfusion, uterine rupture, or unplanned hysterectomy), as well as infant death. Multivariable Poisson regression models were used to estimate adjusted relative risks (aRR) and 95% CIs. RESULTS Among 4.3 million births, 60.6% identified as non-Hispanic White, 14.6% identified as non-Hispanic Black, and 24.8% identified as Hispanic. The rate of primary cesarean delivery was 18.5% (n=804,155). An increased risk for cesarean delivery was found in non-Hispanic Black (21.7%, aRR 1.24, 95% CI 1.23-1.25) and Hispanic (17.3%, aRR 1.09, 95% CI 1.09-1.10) individuals, compared with non-Hispanic White individuals (18.1%) after multivariable adjustment. There was an upward trend in the rate of primary cesarean delivery in all racial and ethnic groups ( P for linear trend<0.001 for all groups). However, the racial and ethnic disparity in the rate of primary cesarean delivery remained stable during the study period. The composite neonatal adverse outcome was lower in Hispanic individuals in all newborns (10.7 vs 8.3 per 1,000 live births, aRR 0.74, 95% CI 0.72-0.75), and in newborns delivered by primary cesarean delivery (18.5 vs 15.0 per 1,000 live births, aRR 0.73, 95% CI 0.70-0.76), compared with non-Hispanic White individuals. CONCLUSION Using a nationally representative sample in the United States, we found racial and ethnic disparities in the primary cesarean delivery rate in low-risk nulliparous patients, which persisted throughout the study period.
Collapse
Affiliation(s)
- Michal Fishel Bartal
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, UTHealth Houston, Houston, Texas; and the Department of Obstetrics and Gynecology, Alpert Medical School, Brown University, Providence, Rhode Island
| | | | | | | | | |
Collapse
|
32
|
Zhong X, Lin R, Zhang W, Huang S, Luo Y, Wang D. Epidemiology and clinical features of maternal sepsis: A retrospective study of whole pregnancy period. Medicine (Baltimore) 2022; 101:e30599. [PMID: 36221418 PMCID: PMC9543042 DOI: 10.1097/md.0000000000030599] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Maternal sepsis results in poor outcomes such as fetal or maternal death. The incidence and mortality rates of maternal sepsis vary in different places because of differences in economic development, race and medical conditions. Identifying the clinical features and determining possible mechanisms for avoiding morbidity and preventing poor outcomes would benefit committed patients. Therefore, this was an epidemiological study at a maternity transfer center in Southeast China that aimed to identify local disease features of maternal sepsis. To investigate the incidence and risk factors associated with maternal sepsis and its progression to severe sepsis in a large population-based birth cohort. This local epidemiological study was conducted in at a tertiary care center in Guangzhou, China, from 2015 to 2019. A total of 74,969 pregnant women experiencing childbirth were included in this study; Of these, 74 patients with maternal sepsis were diagnosed according to the sepsis criterion, and 118 patients without sepsis in the same period were selected randomly as the control group to study possible reasons for postpartum sepsis. This retrospective analysis covered the entire period from the first trimester to puerperium. Clinical data were collected using the hospital's electronic medical record system. Multivariate logistic regression was used to analyze risk factors for maternal sepsis. The incidences of maternal sepsis, the maternal mortality, and the fetal mortality were 0.099%, 0.004%, and 0.007%, respectively. Septic shock was associated with a higher severity of illness. All poor outcomes (maternal or fetal death) occurred during pregnancy. Postpartum sepsis had the longest onset period, and was associated with premature rupture of fetal membranes and preeclampsia. Sepsis is an important cause of both maternal and fetal mortality. Herein, we describe an epidemiological study that evaluated the incidence, development, and prognosis of local maternal sepsis. Furthermore, the characteristics of maternal sepsis are likely due to unknown pathological mechanisms, and patients would benefit from identifying more effective treatments for maternal sepsis.
Collapse
Affiliation(s)
- Xuan Zhong
- Medical Intensive Care Unit, Guangdong Women and Children Hospital, Guangzhou, Guangdong, China
| | - Rongfeng Lin
- School of Pharmaceutical Sciences, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Wenni Zhang
- Medical Intensive Care Unit, Guangdong Women and Children Hospital, Guangzhou, Guangdong, China
| | - Shan Huang
- Medical Intensive Care Unit, Guangdong Women and Children Hospital, Guangzhou, Guangdong, China
| | - Yiping Luo
- Medical Intensive Care Unit, Guangdong Women and Children Hospital, Guangzhou, Guangdong, China
| | - Ding Wang
- Department of Obstetrics and Gynecology, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
- Key Laboratory of Reproduction and Genetics of Guangdong Higher Education Institutes, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
- * Correspondence: Ding Wang, Department of Obstetrics and Gynecology, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, No. 63 Duobao Road, Guangzhou, Guangdong 510150, China (e-mail: l)
| |
Collapse
|
33
|
Castillo AF, Davis AL, Krishnamurti T. Using implementation science frameworks to translate and adapt a pregnancy app for an emerging Latino community. BMC Womens Health 2022; 22:386. [PMID: 36131336 PMCID: PMC9490971 DOI: 10.1186/s12905-022-01975-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/09/2022] [Indexed: 12/02/2022] Open
Abstract
Background Digital mobile health (mHealth) applications are a popular form of prenatal education and care delivery in the U.S.; yet there are few Spanish language options for native speakers. Furthermore, existing applications do not consider cultural differences and disparities in healthcare access, including those specific to emerging Latino communities. Objective To adapt and translate an English-language pregnancy mobile health app to meet the language and cultural needs of Spanish-speaking Latino immigrants living in the United States. Methods We use a multi-step process, grounded in implementation science frameworks, to adapt and translate the contents of an existing pregnancy app. Interviews with stakeholders (n = 12) who advocate for the needs of pregnant individuals in an emerging Latino community were used to identify domains of possible disparities in access to prenatal care. We then conducted semi-structured interviews with peripartum Spanish-speaking Latino users (n = 14) to understand their perspectives within those domains. We identified a list of topics to create educational material for the modified app and implemented a systematic translation approach to ensure that the new version was acceptable for immigrants from different countries in Latin America. Results The interviews with stakeholders revealed seven critical domains that need to be addressed in an adapted prenatal app: language and communication, financial concerns, social support, immigration status, cultural differences, healthcare navigation, and connection to population-specific community resources that offer Spanish language services. The interviews with peripartum Spanish-speaking Latino women informed how the existing content in the app could be adjusted or built upon to address these issues, including providing information on accessing care offered in their native language and community support. Finally, we used a systematic approach to translate the existing application and create new content. Conclusion This work illustrates a process to adapt an mHealth pregnancy app to the needs of an emerging Latino community, by incorporating culturally sensitive Spanish language content while focusing on addressing existing health disparities.
Collapse
|
34
|
Associations of anaemia and race with peripartum transfusion in three United States datasets. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2022; 20:374-381. [PMID: 34967729 PMCID: PMC9480970 DOI: 10.2450/2021.0217-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/04/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Transfusion complicates a significant proportion of births in the United States, and Black women have greater prevalence of transfusion at delivery than White women. Antepartum anaemia, a risk factor for peripartum transfusion, is more common among Black women than White women. We aimed to describe the racial distribution of antepartum anaemia in three national datasets and to evaluate the peripartum transfusion rate and characteristics of transfusion recipients, to investigate disparities in haemostatic outcomes. MATERIAL AND METHODS We performed a retrospective analysis of Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network Cesarean Registry (CR), NICHD Consortium on Safe Labor Registry (CSL), and a cohort of deliveries at Universal Health Services hospitals (UHS). Univariable associations and multivariable logistic regressions were calculated between race, anaemia and transfusion. Covariates included age, parity, smoking, body mass index, type of insurance, and delivery mode. RESULTS We included n=56,964 deliveries from CR (28% Black), 87,465 from UHS (12% Black), and 140,324 from CSL (24% Black). Anaemia prevalence was 8% in CR, 7% in UHS, and 13% in CSL. Anaemia was more common among Black patients (ORs 2.52, 2.61, and 1.48 respectively) and was associated with transfusion in all databases (ORs 6.46 [95% CI 5.78-7.22]; 5.79 [4.74-7.27]; 1.27 [1.18-1.37] respectively). After adjusting for covariates, Black patients had greater odds of transfusion than non-Black patients in CR (aOR 1.32 [1.16-1.50]), but not in UHS or CSL (aORs 1.19 [0.89-1.59] and 0.40 [0.36-0.44] respectively). DISCUSSION In our retrospective cohort study using three US registries, we emphasized the link between anaemia and transfusion. Although anaemia was more prevalent among Black patients, the race-transfusion relationship differed between databases, indicating other unexplored factors are involved.
Collapse
|
35
|
da Silva PHA, Aiquoc KM, da Silva Nunes AD, Medeiros WR, de Souza TA, Jerez-Roig J, Barbosa IR. Prevalence of Access to Prenatal Care in the First Trimester of Pregnancy Among Black Women Compared to Other Races/Ethnicities: A Systematic Review and Meta-Analysis. Public Health Rev 2022; 43:1604400. [PMID: 35860809 PMCID: PMC9289875 DOI: 10.3389/phrs.2022.1604400] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 05/23/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: To analyze the prevalence of access to prenatal care in the first trimester of pregnancy among black women compared to other races/ethnicities through a systematic review and meta-analysis.Methods: Searches were carried out at PUBMED, LILACS, Web of Science, Scopus, CINAHL, and in the grey literature. The quality of the studies and the risk of bias were analyzed using the Joanna Briggs Critical Appraisal Checklist for Analytical Cross-Sectional Studies instrument. The extracted data were tabulatesd and analyzed qualitatively and quantitatively through meta-analysis.Results: Black women had the lowest prevalence of access to prenatal services in the first trimester, with prevalence ranging from 8.1% to 74.81%, while among white women it varied from 44.9 to 94.0%; 60.7% of black women started prenatal care in the first trimester, while 72.9% of white women did so.Conclusion: Black women compared to other racial groups had lower prevalence of access to prenatal care, with less chance of access in the first trimester, and it can be inferred that the issue of race/skin color is an important determinant in obtaining obstetric care.Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020159968_, PROSPERO CRD42020159968.
Collapse
Affiliation(s)
| | - Kezauyn Miranda Aiquoc
- Postgraduate Program in Public Health, Federal University of Rio Grande do Norte, Natal, Brazil
| | | | | | - Talita Araujo de Souza
- Postgraduate Program in Public Health, Federal University of Rio Grande do Norte, Natal, Brazil
- *Correspondence: Talita Araujo de Souza,
| | - Javier Jerez-Roig
- Faculty of Health Sciences and Welfare, University of Vic–Central University of Catalonia, Barcelona, Spain
| | | |
Collapse
|
36
|
Brazier E, Borrell LN, Huynh M, Kelly EA, Nash D. Variation and racial/ethnic disparities in Caesarean delivery at New York City hospitals: The contribution of hospital-level factors. Ann Epidemiol 2022; 73:1-8. [PMID: 35728734 DOI: 10.1016/j.annepidem.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 06/08/2022] [Accepted: 06/10/2022] [Indexed: 11/15/2022]
Abstract
PURPOSE We aimed to quantify general and specific contextual effects associated with Caesarean delivery at New York City (NYC) hospitals, overall and by maternal race/ethnicity. METHODS Among 127,449 singleton, nulliparous births at NYC hospitals from 2015 to 2017, we used multilevel logistic regression to examine the association of hospital characteristics (public/private ownership, teaching status and delivery caseloads) with Caesarean delivery, overall, and by maternal race/ethnicity. We estimated the intra-class correlation (ICC) to examine general contextual effects and 80% interval odds ratios (IOR) and percentage of opposed odds ratios (POOR) to examine specific contextual effects. RESULTS Overall, 27.8% of births were Caesareans. The general contextual (hospital) effect on Caesarean delivery was small (ICC: 1.8%). Hospital characteristics associated with Caesarean delivery differed by maternal race/ethnicity, with delivery in teaching hospitals reducing the odds of Caesarean delivery among White (IOR: 0.31, 0.86; POOR: 4.7%) and Asian women (IOR: 0.41, 0.95; POOR: 7.3%), but not among Black (IOR: 0.51, 1.34; POOR: 30.7%) or Hispanic women (IOR: 0.44, 1.24; POOR: 22.6%). Hospital ownership and caseloads were not associated with Caesarean delivery for any group. CONCLUSION There is little within-hospital clustering of Caesarean delivery, suggesting that Caesarean disparities may not be explained by hospital of delivery.
Collapse
Affiliation(s)
- Ellen Brazier
- Institute for Implementation Science in Population Health (ISPH), Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, NY; Department of Epidemiology & Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, NY.
| | - Luisa N Borrell
- Department of Epidemiology & Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, NY
| | - Mary Huynh
- Office of Vital Statistics, Bureau of Vital Statistics, NYC Department of Health and Mental Hygiene, New York, NY
| | - Elizabeth A Kelly
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, OH
| | - Denis Nash
- Institute for Implementation Science in Population Health (ISPH), Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, NY; Department of Epidemiology & Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, NY
| |
Collapse
|
37
|
Gu S, Pei J, Zhou C, Zhao X, Wan S, Zhang J, Adanlawo A, Luo Z, Wu G, Hua X. Selective versus routine use of episiotomy for vaginal births in Shanghai hospitals, China: a comparison of policies. BMC Pregnancy Childbirth 2022; 22:475. [PMID: 35690738 PMCID: PMC9188710 DOI: 10.1186/s12884-022-04790-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/24/2022] [Indexed: 11/23/2022] Open
Abstract
Background To assess the effects of policy of selective versus routine episiotomy on mother and baby for women delivering vaginally in Shanghai and whether the hospital type has any effect on the outcomes. Method This was a multi-center retrospective cohort study in Shanghai between March 2015 and May 2017. The study population were vaginal births with selective or routine episiotomy (n = 5478) in 20 secondary or tertiary hospitals. Main Outcome Measure was the incidence of severe perineal lacerations. The adjusted odds ratios (aOR) and 95% confidence intervals (CI) were estimated by logistic regression and presented as the effect sizes. All models were stratified by the utilization of level (secondary and tertiary) and type (general and Obstetric) of hospital. Results The primary outcome was not significantly different between vaginal births with routine and selective episiotomy. Patients with selective episiotomy had a lower risk of postpartum hemorrhage, and newborns in the selective episiotomy group had a lower risk of shoulder dystocia and Neonatal Ward compared to those with routine episiotomy. Newborns in selective episiotomy group had a lower risk of birth injury in tertiary hospital. However, newborns in selective episiotomy group had a higher risk of birth injury in general hospitals. Conclusion Selective episiotomy is safe and can be recommended over routine episiotomy in obstetric and tertiary hospital settings in China. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04790-0.
Collapse
Affiliation(s)
- Shengyi Gu
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Jindan Pei
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Chenchen Zhou
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Xiaobo Zhao
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Sheng Wan
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Jun Zhang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, and Department of Obstetrics, Xinhua Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, 200092, China
| | - Adewumi Adanlawo
- Department of Obstetrics and Gynecology, Saskatchewan Health Authority, Regina, SK, Canada
| | - Zhongcheng Luo
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, and Department of Obstetrics, Xinhua Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, 200092, China.,Lunenfeld-Tanenbaum Research Institute, Prosserman Centre for Population Health Research, Department of Obstetrics and Gynecology, Mount Sinai Hospital, Faculty of Medicine, University of Toronto, Toronto, M5G 1X5, Canada
| | - Guizhu Wu
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, China.
| | - Xiaolin Hua
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, China.
| |
Collapse
|
38
|
Impact of Implementation of the Maternal Fetal Triage Index on Patients Presenting with Severe Hypertension. Am J Obstet Gynecol 2022; 227:521.e1-521.e8. [PMID: 35697094 DOI: 10.1016/j.ajog.2022.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 05/25/2022] [Accepted: 06/03/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Severe hypertension remains one of the leading preventable causes of maternal mortality in the United States. Timeliness to response to severe hypertension in pregnancy is a critical quality indicator tracked by state and national organizations. We hypothesized that implementation of the Maternal Fetal Triage Index, a validated acuity tool, would improve care performance in women with severe hypertension in an urban, inner-city hospital setting. OBJECTIVE Our objective was to assess the impact of the Maternal Fetal Triage Index on the management of women presenting with severe pre-eclampsia diagnosed by severe hypertension as measured by time to provider assessment, administration of magnesium sulfate, and immediate administration of acute antihypertensives. STUDY DESIGN This was a prospective, observational study of pregnant women presenting to labor and delivery triage unit with severe pre-eclampsia diagnosed by severe hypertension delivering at a large urban inner-city academic facility before (Epoch 1: January 1, 2019- December 31, 2019) and after (Epoch 2: March 1, 2021- September 31, 2021) implementation of the Maternal Fetal Triage Index. Baseline outcomes of time to assessment, time to magnesium sulfate prophylaxis, and time to antihypertensive medication administration prior to implementation of the Maternal Fetal Triage Index were assessed. The Maternal Fetal Triage Index tool was implemented on March 1, 2021, following standardized education in 2020 for all triage nurses, unit technicians, healthcare unit coordinators, and healthcare providers. Time to assessment, administration of magnesium sulfate prophylaxis, and time to antihypertensive administration following implementation of the Maternal Fetal Triage Index were compared with pre- Maternal Fetal Triage Index measures. Statistical analysis included Wilcoxon rank sum test with P< 0.05 considered significant when comparing epoch 1 to epoch 2. RESULTS A total of 370 patients were admitted with severe hypertension in 2019 prior to the use of the Maternal Fetal Triage Index, and 254 patients were admitted with severe hypertension in 2021 after the Maternal Fetal Triage Index was implemented. There were no differences between epochs across baseline characteristics including age, race/ethnicity, parity, and body mass index. After the Maternal Fetal Triage Index was implemented, time to provider assessment was significantly improved, from median time of 44 [0, 65] minutes in epoch 1 to 17 [0, 39] minutes, P<0.001 in epoch 2. Time from arrival to magnesium sulfate prophylaxis was also significantly faster with median time of 161 [109, 256] minutes in epoch 1 vs. 127 [85, 258] minutes, P=0.001 in epoch 2. There was also a decrease in time from arrival to antihypertensive medication administration for severe blood pressures after implementation of the Maternal Fetal Triage Index (101[61, 177] minutes vs 66 [35, 203] minutes, P<0.001). CONCLUSIONS Implementation of the Maternal Fetal Triage Index at a large urban inner-city hospital was associated with improved timeliness of assessment and treatment of women with severe hypertension. The Maternal Fetal Triage Index is a viable mechanism to improve efficiency among triage units- specifically in the management of severe hypertension.
Collapse
|
39
|
Katz D, Khadge S, Carvalho B. Comparing Postpartum Estimated and Quantified Blood Loss Among Racial Groups: An Observational Study. Cureus 2022; 14:e25299. [PMID: 35755558 PMCID: PMC9225058 DOI: 10.7759/cureus.25299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2022] [Indexed: 11/29/2022] Open
Abstract
Objective: Racial and ethnic disparities in peripartum blood loss and postpartum hemorrhage (PPH) have not been adequately evaluated. We sought to compare postpartum blood loss and PPH in African American and Hispanic parturients compared to other groups. Methods: This was a secondary analysis of an observational study at a tertiary academic center of a historical (August 2016 to January 2017) and interventional (August 2017 to January 2018) cohort of 7618 deliveries. Visual estimation of blood loss (EBL) was used in the historical group and quantitative blood loss (QBL) was implemented in the intervention group. Our primary endpoint was median blood loss in African Americans versus other racial groups between cohorts. Results: A total of 7618 deliveries were evaluated; 755 (9.9%) were identified as African American with 1035 (13.6%) identifying as Hispanic. Blood loss was similar in racial groups using EBL (p=0.131), but not QBL that was 430 (227-771) in African Americans and 348 (200-612) in non-African Americans (p<0.001). PPH was greater among African Americans in both groups (10.3% vs. 6.9% in EBL cohort, p=0.023, and 16.9% vs. 11.6% in QBL cohort, p<0.001). Conclusion: Racial and ethnic differences in peripartum blood loss were more apparent with QBL than EBL. It is unknown if these differences are caused by provider cognitive bias, socioeconomic differences, language barriers and/or other factors.
Collapse
|
40
|
Development of clinical risk-prediction models for uterine atony following vaginal and cesarean delivery. Int J Obstet Anesth 2022; 51:103550. [DOI: 10.1016/j.ijoa.2022.103550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 04/13/2022] [Accepted: 04/15/2022] [Indexed: 11/20/2022]
|
41
|
Dude AM, Schueler K, Schumm LP, Murugesan M, Stulberg DB. Preconception care and severe maternal morbidity in the United States. Am J Obstet Gynecol MFM 2022; 4:100549. [PMID: 34871778 PMCID: PMC8891086 DOI: 10.1016/j.ajogmf.2021.100549] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/01/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND In the United States, approximately 52,000 women per year (accounting for 1.46% of births) experience severe maternal morbidity, which is defined as a complication that causes significant maternal harm or risk of death. It disproportionately affects women from racial or ethnic minorities, people with chronic diseases, and those with Medicaid or no insurance. Preconception care has been hailed as a strategy to improve pregnancy outcomes and reduce disparities, but its broad benefits for maternal outcomes have not been demonstrated. OBJECTIVE Our objective was to measure the association between preconception care and the odds of severe maternal morbidity among women with Medicaid. STUDY DESIGN This is a secondary analysis of Medicaid claims using the Medicaid Analytic Extract files (2010-2012). We used the International Classification of Diseases, Ninth Revision codes, published by the US Office of Population Affairs' Quality Family Planning program to define 7 domains of preconception care. The primary outcome was maternal death within 12 weeks of delivery or severe maternal morbidity during birth hospitalization, defined by the presence of any diagnosis or procedure on the severe maternal morbidity International Classification of Diseases, Ninth Revision code list from the Centers for Disease Control and Prevention. Because this list may overestimate severe maternal morbidity by counting any blood transfusion, our secondary outcome used the same code list but without transfusion. We reviewed care in the year before conception and used logistic regression to estimate the association between each domain and severe maternal morbidity for all births to women enrolled in Medicaid and aged 15 to 45 years with births during 2012. We performed a subgroup analysis for women with chronic disease (kidney disease, hypertension, or diabetes). RESULTS Severe maternal morbidity or death occurred in 26,285 births (1.74%) when including blood transfusions and 9,481 births (0.63%) when excluding transfusions. Receiving contraceptive services in the year before conception was associated with decreased odds of severe maternal morbidity (adjusted odds ratio, 0.92; 95% confidence interval, 0.88-0.95) and pregnancy test services were associated with increased odds (adjusted odds ratio, 1.08; 95% confidence interval, 1.01-1.14). In the primary analysis, no significant associations were observed for other preconception care domains. Among those women with at least 1 chronic disease, contraceptive care (adjusted odds ratio, 0.84; 95% confidence interval, 0.75-0.95) and routine physical or gynecologic exams (adjusted odds ratio, 0.79; 95% confidence interval, 0.71-0.88) were associated with decreased odds of severe maternal morbidity. Similar associations were found for severe maternal morbidity when excluding blood transfusion. CONCLUSIONS Contraceptive services in the year before conception and routine exams for women with chronic disease are associated with decreased odds of severe maternal morbidity or death for Medicaid enrollees.
Collapse
|
42
|
Emeruwa UN, Gyamfi-Bannerman C, Miller RS. Health Care Disparities in the COVID-19 Pandemic in the United States: A Focus on Obstetrics. Clin Obstet Gynecol 2022; 65:123-133. [PMID: 35045035 PMCID: PMC8767922 DOI: 10.1097/grf.0000000000000665] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The influence of social determinants of health on disease dynamics and outcomes has become increasingly clear, making them a prime target of investigation and mitigation efforts. The obstetric population is uniquely positioned to provide insight into the health inequities exacerbated by the coronavirus disease 2019 pandemic given their susceptibility to infectious disease morbidity and frequent interactions with the health care system, which provide opportunities for ascertainment of disease incidence and severity. This review summarizes the data on disparities identified in the US obstetric population during the coronavirus disease 2019 pandemic as they relate to race and ethnicity, built environment, insurance status, language, and immigration status.
Collapse
Affiliation(s)
- Ukachi N. Emeruwa
- Division of Maternal- Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Cynthia Gyamfi-Bannerman
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego School of Medicine, UC San Diego Health, La Jolla, California
| | - Russell S. Miller
- Division of Maternal- Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
| |
Collapse
|
43
|
Postpartum Length of Stay and Hospital Readmission Before and During the Coronavirus Disease 2019 (COVID-19) Pandemic. Obstet Gynecol 2022; 139:381-390. [PMID: 35115443 DOI: 10.1097/aog.0000000000004687] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/02/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To compare postpartum hospitalization length of stay (LOS) and hospital readmission among obstetric patients before (March 2017-February 2020; prepandemic) and during the coronavirus disease 2019 (COVID-19) pandemic (March 2020-February 2021). METHODS We conducted a retrospective cohort study, using Epic Systems' Cosmos research platform, of obstetric patients who delivered between March 1, 2017, and February 28, 2021, at 20-44 weeks of gestation and were discharged within 7 days of delivery. The primary outcome was short postpartum hospitalization LOS (less than two midnights for vaginal births and less than three midnights for cesarean births) and secondary outcome was hospital readmission within 6 weeks of postpartum hospitalization discharge. Analyses compared outcomes before and during the pandemic using standardized differences and Bayesian logistic mixed-effects models, among all births and stratified by mode of delivery. RESULTS Of the 994,268 obstetric patients in the study cohort, 742,113 (74.6%) delivered prepandemic and 252,155 (25.4%) delivered during the COVID-19 pandemic. During the COVID-19 pandemic, the percentage of short postpartum hospitalizations increased among all births (28.7-44.5%), vaginal births (25.4-39.5%), and cesarean births (35.3-55.1%), which was consistent with the adjusted analysis (all births: adjusted odds ratio [aOR] 2.35, 99% credible interval 2.32-2.39; vaginal births: aOR 2.14, 99% credible interval 2.11-2.18; cesarean births aOR 2.90, 99% credible interval 2.83-2.98). Although short postpartum hospitalizations were more common during the COVID-19 pandemic, there was no change in readmission in the unadjusted (1.4% vs 1.6%, standardized difference=0.009) or adjusted (aOR 1.02, 99% credible interval 0.97-1.08) analyses for all births or when stratified by mode of delivery. CONCLUSION Short postpartum hospitalization LOS was significantly more common during the COVID-19 pandemic for obstetric patients with no change in hospital readmissions within 6 weeks of postpartum hospitalization discharge. The COVID-19 pandemic created a natural experiment, suggesting shorter postpartum hospitalization may be reasonable for patients who are self-identified or health care professional-identified as appropriate for discharge.
Collapse
|
44
|
Daymude AEC, Daymude JJ, Rochat R. Labor and Delivery Unit Closures in Rural Georgia from 2012 to 2016 and the Impact on Black Women: A Mixed-Methods Investigation. Matern Child Health J 2022; 26:796-805. [PMID: 35182306 DOI: 10.1007/s10995-022-03380-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Obstetric provider coverage in rural Georgia has worsened, with nine rural labor and delivery units (LDUs) closing outside the Atlanta Metropolitan Statistical Area from 2012 to 2016. Georgia consistently has one of the highest maternal mortality rates in the nation and faces increased adverse health consequences from this decline in obstetric care. OBJECTIVE This study explores what factors may be associated with rural hospital LDU closures in Georgia from 2012 to 2016. METHODS This study describes differences between rural Georgia hospitals based on LDU closure status through a quantitative analysis of 2011 baseline regional, hospital, and patient data, and a qualitative analysis of newspaper articles addressing the closures. RESULTS LDUs that closed had higher proportions of Black female residents in their Primary Care Service Areas (PCSAs), of Black birthing patients, and of patients with Medicaid, self-pay or other government insurance; lower LDU birth volume; more women giving birth within their PCSA of residence; fewer obstetricians and obstetric provider equivalents per LDU; and fewer average annual births per obstetric provider. Qualitative results indicate financial distress primarily contributed to closures, but also suggest that low birth volume and obstetric provider shortage impacted closures. CONCLUSIONS FOR PRACTICE Rural LDU closure in Georgia has a disproportionate impact on Black and low-income women and may be prevented through funding maternity healthcare, financing LDUs, and addressing provider shortages.
Collapse
Affiliation(s)
- Anna E Carson Daymude
- Rollins School of Public Health, Emory University, Grace Crum Rollins Building 1518 Clifton Rd., Atlanta, GA, 30322, USA.
| | - Joshua J Daymude
- Biodesign Center for Biocomputing, Security and Society, Arizona State University, 727 E. Tyler St., Tempe, AZ, 85281, USA
| | - Roger Rochat
- Rollins School of Public Health, Emory University, Grace Crum Rollins Building 1518 Clifton Rd., Atlanta, GA, 30322, USA
| |
Collapse
|
45
|
Bunn JG, Sheeder J, Schulkin J, Diko S, Estin M, Connell KA, Hurt KJ. Obstetric anal sphincter injuries and other delivery trauma: a US national survey of obstetrician-gynecologists. Int Urogynecol J 2022; 33:1463-1472. [PMID: 35113178 DOI: 10.1007/s00192-021-05062-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 12/01/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Obstetric lacerations complicate the majority of deliveries. The application of standardized guidelines for assessing delivery trauma has not been assessed thoroughly in the United States. We recently identified gaps in US midwives' clinical assessment of delivery trauma. We conducted a cross-sectional national survey of practicing obstetricians in the USA to characterize their classification of obstetric lacerations. We hypothesized that attending obstetricians' identification and diagnosis of delivery trauma would be similar to our findings for midwives with frequent inaccuracy. METHODS We recruited clinically active obstetricians through the Pregnancy-Related Care Research Network. We asked participants to classify (from written definitions) and diagnose (from standard illustrations) common forms of vaginal delivery trauma using the widely employed perineal laceration degree system. We performed bivariate analysis of high- and low-scoring respondents and logistic regression to model characteristics associated with higher diagnostic accuracy. RESULTS Of the 162 respondents who started the survey, 76% (123) were included for analysis (22% of solicited emails). Overall, we found wide variation in response accuracy with as few as 62% of respondents correctly classifying certain types of lacerations. Only 49 out of 123 (40%) use the Sultan third-degree subclassification system and 67 out of 123 (52%) continue to use the midline/median approach for episiotomies. Providers reporting fewer deliveries per month and fewer publicly insured patients earned higher scores. CONCLUSIONS Obstetricians in a nationally representative US perinatal provider network inconsistently identify perineal and nonperineal lacerations. We found important clinical knowledge gaps, suggesting that vaginal delivery diagnoses in obstetric quality studies and pelvic floor research might be inaccurate.
Collapse
Affiliation(s)
- Jason G Bunn
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jeanelle Sheeder
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jay Schulkin
- Pregnancy-Related Care Research Network, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Sindi Diko
- Department of Surgery, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Miriam Estin
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Kathleen A Connell
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Division of Reproductive Sciences, Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - K Joseph Hurt
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA. .,Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, 12700 E 19th Avenue, Mailstop 8613, Research Complex-2, P15-3003, Aurora, CO, 80045, USA.
| |
Collapse
|
46
|
Wouk K, Kinlaw AC, Farahi N, Pfeifer H, Yeatts B, Paw MK, Robinson WR. Correlates of Receiving Guideline-Concordant Postpartum Health Services in the Community Health Center Setting. WOMEN'S HEALTH REPORTS 2022; 3:180-193. [PMID: 35262055 PMCID: PMC8896220 DOI: 10.1089/whr.2021.0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 11/17/2022]
Abstract
Introduction: New clinical guidelines recommend comprehensive and timely postpartum services across 3 months after birth. Research is needed to characterize correlates of receiving guideline-concordant, quality postpartum care in federally qualified health centers serving marginalized populations. Methods: We abstracted electronic health record data from patients who received prenatal health care at three health centers in North Carolina to characterize quality postpartum care practices and to identify correlates of receiving quality care. We used multivariable log-binomial regression to estimate associations between patient, provider, and health center characteristics and two quality postpartum care outcomes: (1) timely care, defined as an initial assessment within the first 3 weeks and at least one additional visit within the first 3 months postpartum; and (2) comprehensive care, defined as receipt of services addressing family planning, infant feeding, chronic health, mood, and physical recovery across the first 3 months. Results: In a cohort of 253 patients, 60.5% received comprehensive postpartum care and 30.8% received timely care. Several prenatal factors (adequate care use, an engaged patient–provider relationship) and postpartum factors (early appointment scheduling, exclusive breastfeeding, and use of enabling services) were associated with timely postpartum care. The most important correlate of comprehensive services was having more than one postpartum visit during the first 3 months postpartum. Discussion: Identifying best practices for quality postpartum care in the health center setting can inform strategies to reduce health inequities. Future research should engage community stakeholders to define patient-centered measures of quality postpartum care and to identify community-centered ways of delivering this care.
Collapse
Affiliation(s)
- Kathryn Wouk
- Department of Maternal and Child Health, Carolina Global Breastfeeding Institute, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, North Carolina, USA
| | - Alan C. Kinlaw
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina School of Pharmacy, Chapel Hill, North Carolina, USA
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Narges Farahi
- Department of Family Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Henry Pfeifer
- Piedmont Health Services, Chapel Hill, North Carolina, USA
- Department of Physician Assistant Studies, East Carolina University, Greenville, North Carolina, USA
| | - Brandon Yeatts
- Piedmont Health Services, Chapel Hill, North Carolina, USA
- School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Moo Kho Paw
- Piedmont Health Services, Chapel Hill, North Carolina, USA
| | - Whitney R. Robinson
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| |
Collapse
|
47
|
West R, DiMeo A, Langer A, Shah N, Molina RL. Addressing Racial/Ethnic Inequities in Maternal Health Through Community-Based Social Support Services: A Mixed Methods Study. Matern Child Health J 2022; 26:708-718. [PMID: 34982340 PMCID: PMC8724658 DOI: 10.1007/s10995-021-03363-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2021] [Indexed: 11/24/2022]
Abstract
Introduction In the US, there are striking inequities in maternal health outcomes between racial and ethnic groups. Community-based organizations (CBOs) provide social support services that are critical in addressing the needs of clients of color during and after pregnancy. Methods We conducted a descriptive, cross-sectional mixed methods study of CBOs in Greater Boston that provide social support services to pregnant and postpartum clients. In May–August 2020, we administered an online survey about organizational characteristics, client population, and services offered. In July–August 2020, we conducted semi-structured interviews focused on services provided, gaps in services, and the impact of structural racism on clients. We used descriptive statistics to characterize CBOs and services and used thematic analysis to extract themes from the qualitative data. Results A total of 21 unique CBOs participated with 17 CBOs completing the survey and 14 participating in interviews. CBOs served between 10 and 35,000 pregnant and postpartum clients per year (median = 200), and about half (n = 8) focused their programming on pregnant and postpartum clients. The most significant gaps in social support services were housing and childcare. Respondents identified racism and lack of coordination among organizations as the two primary barriers to accessing social support. Discussion CBOs face multiple challenges to providing social support to pregnant and postpartum clients of color, and significant gaps exist in the types of services currently provided. Improved coordination among CBOs and advocacy efforts to develop community-informed solutions are needed to reduce barriers to social support.
Collapse
Affiliation(s)
- Rebecca West
- Boston University School of Public Health, Boston, MA USA
- Ariadne Labs at Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health, Boston, MA USA
| | - Amanda DiMeo
- Ariadne Labs at Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health, Boston, MA USA
| | - Ana Langer
- Women and Health Initiative, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA USA
| | - Neel Shah
- Ariadne Labs at Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health, Boston, MA USA
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - Rose L. Molina
- Ariadne Labs at Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health, Boston, MA USA
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA USA
| |
Collapse
|
48
|
Rossi MA, Vermeir E, Brooks M, Pierce M, Pukall CF, Rosen NO. Comparing Self-Reported Pain During Intercourse and Pain During a Standardized Gynecological Exam at 12- and 24-Month Postpartum. J Sex Med 2022; 19:116-131. [PMID: 36963976 DOI: 10.1016/j.jsxm.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 10/26/2021] [Accepted: 11/01/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND There is limited information about the physical indicators and biopsychosocial predictors of self-reported pain during intercourse and pain during a gynecological examination at 12- and 24-month following childbirth. AIM This longitudinal study aimed to (i) Compare the findings from gynecological exams at 12- and 24-month postpartum for women with minimal vs clinically significant pain during intercourse; (ii) Assess the biomedical and psychosocial correlates of self-reported pain during intercourse and the vestibular pain index (VPI) from the cotton-swab test at 12- and 24-month postpartum; (iii) Establish the relationship between self-reported pain during intercourse and the cotton-swab test. METHODS Women (N = 97 at 12 months postpartum and N = 44 at 24-month postpartum) recruited from a local women's hospital completed online surveys in their first trimester of pregnancy and at 12- and 24-month postpartum to assess pain during intercourse and biopsychosocial variables. Those with clinically significant (pain ≥4/10 on a visual analogue scale) were matched with those reporting minimal pain (pain <3/10) and underwent a gynecological exam including a cotton-swab test. Descriptive analyses, multiple regressions, and bivariate correlations were conducted to address each of the study aims, respectively. MAIN OUTCOME MEASURES (i) Findings from the gynecological examination (ii) Numerical rating scale for the VPI; (iii) Visual analogue scale of pain during intercourse. RESULTS The majority of women in both pain groups had normal physical findings in the gynecological exam. Greater sexual distress and pain catastrophizing at 12- and 24-month postpartum were significantly associated with greater pain during intercourse at each time-point, respectively. Greater pain catastrophizing at 12 months postpartum was significantly associated with greater pain during the cotton-swab test at that time-point. Lower relationship satisfaction at 12 months postpartum was associated with greater VPI ratings at 24 months postpartum. Pain during intercourse and the VPI were moderately and positively correlated. CLINICAL IMPLICATIONS Addressing psychosocial variables may interrupt the maintenance of postpartum pain. Following an initial assessment, self-reported pain intensity may be a suitable proxy for repeated examinations. STRENGTHS & LIMITATIONS This study is the first to describe the physical findings and psychosocial predictors of pain during intercourse and the VPI at 12- and 24-month postpartum. The homogenous and small sample may limit generalizability. CONCLUSION There were no observable physical indicators of clinically significant postpartum pain during intercourse. Psychosocial variables were linked to women's greater postpartum pain during intercourse and VPI ratings.
Collapse
Affiliation(s)
- Meghan A Rossi
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
| | - Ella Vermeir
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Melissa Brooks
- Department of Obstetrics and Gynaecology, IWK Health Centre, Halifax, NS, Canada
| | - Marianne Pierce
- Department of Obstetrics and Gynaecology, IWK Health Centre, Halifax, NS, Canada
| | | | - Natalie O Rosen
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
- Department of Obstetrics and Gynaecology, IWK Health Centre, Halifax, NS, Canada
| |
Collapse
|
49
|
Haug V, Kadakia N, Wang A, Dorante MI, Panayi AC, Kauke-Navarro M, Hundeshagen G, Diehm Y, Fischer S, Hirche C, Kneser U, Pomahac B. “Racial disparities in short-term outcomes after breast reduction surgery - A National Surgical Quality Improvement Project Analysis with 23,268 patients using Propensity Score Matching”. J Plast Reconstr Aesthet Surg 2022; 75:1849-1857. [DOI: 10.1016/j.bjps.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 12/05/2021] [Accepted: 01/09/2022] [Indexed: 11/29/2022]
|
50
|
Eliason EL, Gordon SH. Mental Health and Postpartum Care in California: Implications from California's Provisional Postpartum Care Extension. Womens Health Issues 2021; 32:122-129. [PMID: 34955336 DOI: 10.1016/j.whi.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 10/27/2021] [Accepted: 11/22/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND California's Provisional Postpartum Care Extension (PPCE) extended Medicaid eligibility through 1 year postpartum for women enrolled in Medi-Cal with annual household incomes of 138%-322% of the federal poverty level and maternal mental health diagnoses. METHODS For this cross-sectional descriptive study, we used the 2017 Listening to Mothers in California survey of postpartum women to identify those potentially eligible for PPCE. We then sought to describe their demographic characteristics, self-reported mental health, and utilization of postpartum care and mental health services compared with those with Medi-Cal during pregnancy who did not meet PPCE eligibility criteria. RESULTS Overall, potentially PPCE-eligible women comprised 6.8% of respondents. Among those who did not qualify for PPCE, the primary reason was the absence of self-reported maternal mental health symptoms. Potentially PPCE-eligible women were approximately two-thirds Hispanic/Latina and more than one-third were ages 25 to 29. The most common self-reported mental health symptom was anxiety during pregnancy (78.9%). Among potentially PPCE-eligible women, 8.4% were taking medicine for anxiety/depression postpartum and 16.0% were receiving postpartum counseling/treatment for emotional or mental well-being. CONCLUSIONS Our analyses suggest that PPCE could have extended postpartum coverage eligibility for approximately 30,360 women statewide. However, our findings demonstrate how narrowly defined PPCE eligibility criteria likely excluded many postpartum women in Medi-Cal who would have been left with limited benefits or more cost-sharing under alternative coverage options. This research could inform state and federal policymakers considering other proposals to extend postpartum Medicaid eligibility.
Collapse
Affiliation(s)
- Erica L Eliason
- Columbia University School of Social Work, New York, New York.
| | - Sarah H Gordon
- Boston University School of Public Health, Boston, Massachusetts
| |
Collapse
|