Racial Disparities in Maternal Mortality

1. Racial Disparities in Maternal Mortality Lea m.porche, md Assistant professor, Div of maternal fetal medicine Eastern Virginia medical school, Norfolk, Va

2. Objectives • Data • Reasons • Solutions

4. Black women are 3-4 times more likely to die from factors related to pregnancy or child birth

6. Maternal Mortality VA 2018 Maternal Mortality- Black Maternal Mortality- White

9. Drivers of Disparities • Patient • Provider • System Jain et al, SMFM Reducing Ethnic Disparities in MM, 2017

10. Drivers of Disparities- Patient • Pre-existing medical co-morbidities • Healthcare literacy • Perspectives on healthcare/system • Socio-cultural perspective on health, illness and treatment • Relationship with provider

11. Pre-existing Medical Comorbidities • 12 weeks gestation  140/90 • CHTN prior to pregnancy? • No • Do you have a primary care provider outside of pregnancy? • …No

12. Pre-existing Medical Comorbidities:Hypertension • Hypertension • 40% of AA in the US have HTN • Develops earlier in life • Often more severe • Some genetic predisposition to have increased Na responsiveness • For any given duration of CHTN, black women are more likely to have end organ damage • Differential antihypertensives recommended for treatment Jain 2017, AHA 2016

13. Pre-existing Medical Comorbidities • Obese patient completes early 1hr OGTT  205 • Do you have diabetes outside of pregnancy? • No • Do you have a primary care provider outside of pregnancy? • …No

14. Pre-existing Medical Comorbidities:Diabetes • 30 million children and adults in the US have diabetes • 95% of these are type 2 diabetes • Racial breakdown for diabetes • 7.4% of non-Hispanic whites • 8.0% of Asian Americans • 12.1% of Hispanics • 12.7% of non-Hispanic black • 15.1% of American Indian/Alaskan Natives

15. Pre-existing Medical Comorbidities:Diabetes • Virginia • 884,000 (12.8%) of the adult population have diabetes • 207,000 don’t know they have it • 2,213,000 (36%) have prediabetes • 42,000 new diagnoses each year Centers for Disease Control, American Diabetes Association

16. Pre-existing Medical Comorbidities:Diabetes • Review of data from NHANES survey • 10, 491 women 15-44 self reported NO DIABETES • 6881 with A1C and 4352 with FBS • 30 A1C > 6.5 • 28 FBS > 126 • 61,606,000 women of childbearing age in US • 300,000 with undiagnosed diabetes …...

17. Pre-existing Medical Comorbidities:Obesity

18. Ayemang, Curr, Cardiovasc Risk Rep, 2013

20. Relationship with Provider • African Americans, Hispanics, and Asians remained more likely than whites (P < .001) • 1) they would have received better medical care if they belonged to a different race/ethnic group • 2) medical staff judged them unfairly or treated them with disrespect based on race/ethnicity Johnson et al, J Gen Intern Med 2014

21. Relationship with Provider • 24,000 women surveyed in the UK • Throughout their maternity care, women from minority ethnic groups were less likely to feel spoken to so they could understand, to be treated with kindness, to be sufficiently involved in decisions and to have confidence and trust in the staff. Henderson, BMC Pregnancy Childbirth 2013

22. Listening to Mothers III Survey • Survey 2400 singleton deliveries at US hospitals from 2011-2012 • Over 40% of women reported communication problems in prenatal care • 24% perceived discrimination during their hospitalization for birth. • Having hypertension or diabetes was associated with higher levels of reluctance to ask questions and higher odds of reporting each type of perceived discrimination.

23. Listening to Mothers III Survey • Black and Hispanic (vs. white) women had higher odds of perceived discrimination due to race/ethnicity. • Higher education was associated with more reported communication problems among Black women only. • While having diabetes was associated with perceptions of discrimination among all women, associations were stronger for Black women.

24. Perspectives on Healthcare:Tuskeegee Experiment • 1932-1974 in Macons Co, Alabama • Study conducted by US Public Health Service • 400 AA men with “bad blood” recruited by promising meals and burial funding for participation • Once syphilis was identified, treatment was promised but never given, even though PCN was standard of care1947 • 6 mo 40 years • Disease course documented

25. Perspectives on Healthcare:Tuskeegee Experiment • 2004 Focus group concluded that the Tuskeegee experiment made them suspicious about biomedical research J Natl Med Assoc, 2004

26. Drivers of Disparities- Provider • Medical knowledge • Effective communication • Bias- explicit and implicit

27. Explicit Bias • Beliefs we have about a person or group on a conscious level. Much of the time, these biases and their expression arise as the direct result of a perceived threat. • Racism • Sexism • Ageism

28. Implicit Bias • Attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner.

29. Implicit Bias • Systematic review of studies assessing bias in healthcare • 37 studies were reviewed • 31 found evidence of pro-White or light-skin/anti-Black, Hispanic, American Indian or dark-skin bias among a variety of HCPs across multiple levels of training and disciplines • 14 studies looked at link between implicit bias and outcomes • 8 found no statistically significant association between implicit bias and patient care while 6 studies found that higher implicit bias was associated with disparities in treatment recommendations, expectations of therapeutic bonds, pain management, and empathy.

30. Implicit Bias • 7 studies that examined the impact of implicit provider bias on real-world patient-provider interaction found that providers with stronger implicit bias demonstrated poorer patient-provider communication • More research is needed in reference to implicit bias and real-world outcomes.

31. Drivers of Disparities- System • Access to care • Cost/Insurance coverage • Transportation

32. System 8-9.9%

33. System • Age patterns of proportion of uninsured by race Data source: SIPP 2008, CDC/NCHS, National Vital Statistics System, Sohn, Popul Res Policy Rev 2017

34. System • Insurance Coverage • ACA Provision- family coverage until age 26 • Among women with a recent live birth, the Provision was associated with a decreased likelihood of being uninsured and increased private insurance coverage in the month before pregnancy, a shift from Medicaid to private insurance coverage during pregnancy and at delivery, and an increased likelihood of receiving timely prenatal care. Li et al, Med Care 2018

35. System • Education regarding retroactive coverage • Misinformation leads to late prenatal care

36. System • Logistical access to care • Proximity • Transportation • Phone access

38. Recommendations: SMFM Special Report • Provider • Utilize available preventative strategies (low-dose aspirin) • Assess baseline end organ damage (EKG, echo, renal function) • Follow existing guidelines used by other societies in appropriate situation (HTN, DM)

39. Recommendations: SMFM Special Report • Healthcare System- Provide Supportive Services • Standardize culturally appropriate education materials • Provide transportation vouchers • Translation services • Consider remote/home visits and community based initiatives

40. Recommendations: SMFM Special Report • Hospital Systems • Improve quality of care by implementing bundles related to HTN, VTE prevention, and postpartum hemorrhage • Partner with low-resource hospitals to improve care delivery

41. Maternal Mortality Reviews You can’t optimize what you can’t measure, and you can’t measure what you can’t monitor

42. Recommendations • Postpartum visit as a tool for continued care