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El Ayadi AM, Lyndon A, Kan P, Mujahid MS, Leonard SA, Main EK, Carmichael SL. Trends and Disparities in Severe Maternal Morbidity Indicator Categories during Childbirth Hospitalization in California from 1997 to 2017. Am J Perinatol 2024; 41:e3341-e3350. [PMID: 38057087 DOI: 10.1055/a-2223-3520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
OBJECTIVE Severe maternal morbidity (SMM) is increasing and characterized by substantial racial and ethnic disparities. Analyzing trends and disparities across time by etiologic or organ system groups instead of an aggregated index may inform specific, actionable pathways to equitable care. We explored trends and racial and ethnic disparities in seven SMM categories at childbirth hospitalization. STUDY DESIGN We analyzed California birth cohort data on all live and stillbirths ≥ 20 weeks' gestation from 1997 to 2017 (n = 10,580,096) using the Centers for Disease Control and Prevention's SMM index. Cases were categorized into seven nonmutually exclusive indicator categories (cardiac, renal, respiratory, hemorrhage, sepsis, other obstetric, and other medical SMM). We compared prevalence and trends in SMM indicator categories overall and by racial and ethnic group using logistic and linear regression. RESULTS SMM occurred in 1.16% of births and nontransfusion SMM in 0.54%. Hemorrhage SMM occurred most frequently (27 per 10,000 births), followed by other obstetric (11), respiratory (7), and sepsis, cardiac, and renal SMM (5). Hemorrhage, renal, respiratory, and sepsis SMM increased over time for all racial and ethnic groups. The largest disparities were for Black individuals, including over 3-fold increased odds of other medical SMM. Renal and sepsis morbidity had the largest relative increases over time (717 and 544%). Sepsis and hemorrhage SMM had the largest absolute changes over time (17 per 10,000 increase). Disparities increased over time for respiratory SMM among Black, U.S.-born Hispanic, and non-U.S.-born Hispanic individuals and for sepsis SMM among Asian or Pacific Islander individuals. Disparities decreased over time for sepsis SMM among Black individuals yet remained substantial. CONCLUSION Our research further supports the critical need to address SMM and disparities as a significant public health priority in the United States and suggests that examining SMM subgroups may reveal helpful nuance for understanding trends, disparities, and potential needs for intervention. KEY POINTS · By SMM subgroup, trends and racial and ethnic disparities varied yet Black individuals consistently had highest rates.. · Hemorrhage, renal, respiratory, and sepsis SMM significantly increased over time.. · Disparities increased for respiratory SMM among Black, U.S.-born Hispanic and non-U.S.-born Hispanic individuals and for sepsis SMM among Asian or Pacific Islander individuals..
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Affiliation(s)
- Alison M El Ayadi
- Department of Obstetrics, Gynecology and Reproductive Sciences, Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Audrey Lyndon
- NYU Rory Meyers College of Nursing, New York, New York
| | - Peiyi Kan
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Mahasin S Mujahid
- Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, California
| | - Stephanie A Leonard
- Department of Obstetrics and Gynecology, Dunlevie Maternal-Fetal Medicine Center, Stanford University School of Medicine, Stanford, California
| | - Elliott K Main
- Department of Obstetrics and Gynecology, Dunlevie Maternal-Fetal Medicine Center, Stanford University School of Medicine, Stanford, California
| | - Suzan L Carmichael
- Department of Pediatrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, California
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Bruce KE, Desai S, Reilly K, Keil A, Swanson M, Cobb B, Zahn K, McKenzie C, Coviello E, Mallampati D, Tully KP, Kolarczyk L, Maaske S, Quist-Nelson J. Use of Postpartum Hemorrhage Checklist during Vaginal Deliveries: A Quality Improvement Study. Am J Perinatol 2024. [PMID: 38452794 DOI: 10.1055/a-2282-8923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
OBJECTIVE Postpartum hemorrhage (PPH) protocols improve patient safety and reduce utilization of blood products; however, few data exist on sustainability of PPH checklist use, how use affects care delivery, and variation of use among patient subgroups. This study aimed to (1) examine compliance with PPH checklist use during vaginal deliveries, (2) evaluate whether checklist use varied by patient and/or care team characteristics, and (3) evaluate whether checklist use was associated with increased use of recommended medications/interventions. STUDY DESIGN This was a quality improvement study performed from April 2021 through June 2023. A multidisciplinary team developed a revised PPH checklist and used quality improvement methodology to increase checklist use following vaginal birth. Data were collected from medical records and clinician survey. Control charts were generated to track checklist use and evaluate special cause variation. Chi-square tests and logistic regression were used to evaluate variation in medications/interventions and across subgroups. RESULTS During the study period, there were 342 cases of PPH at the time of vaginal birth. The checklist was used in 67% of PPH cases during the 20-month period after implementation in a setting where no checklist was previously being used. We found no statistically significant differences in checklist use by patient or health care team characteristics. Use of tranexamic acid, carboprost, and misoprostol were significantly associated with checklist use. CONCLUSION This study demonstrated successful implementation of a checklist protocol where no checklist was previously being used, with sustained use in an average of 67% of PPH cases over 20 months. Checklist use was consistent across subgroups and was associated with higher use of interventions shown to lower blood loss. KEY POINTS · Our study showed sustainability of PPH checklist use over a 20-month period.. · PPH checklist use was associated with increased use of interventions known to reduce blood loss.. · Checklist was used consistently across patient subgroups; may help address inequities in obstetric outcomes..
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Affiliation(s)
- Katharine E Bruce
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC
| | - Shivani Desai
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Kelly Reilly
- Institute for Healthcare Quality Improvement, University of North Carolina Health, Chapel Hill, NC
| | - Arianna Keil
- Institute for Healthcare Quality Improvement, University of North Carolina Health, Chapel Hill, NC
| | - Michelle Swanson
- Department of Women's Services, University of North Carolina Health, Chapel Hill, NC
| | - Benjamin Cobb
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Katelin Zahn
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Christine McKenzie
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Elizabeth Coviello
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Divya Mallampati
- Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, CA
| | - Kristin P Tully
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Lavinia Kolarczyk
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Shannon Maaske
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Johanna Quist-Nelson
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
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Johnson JD. Black Pregnancy-Related Mortality in the United States. Obstet Gynecol Clin North Am 2024; 51:1-16. [PMID: 38267121 DOI: 10.1016/j.ogc.2023.11.005] [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: 01/26/2024]
Abstract
The maternal mortality rate for non-Hispanic Black birthing people is 69.9 deaths per 100,000 live births compared with 26.6 deaths per 100,000 live births for non-Hispanic White birthing people. Black pregnancy-related mortality has been underrepresented in research and the media; however, there is growing literature on the role of racism in health disparities. Those who provide care to Black patients should increase their understanding of racism's impact and take steps to center the experiences and needs of Black birthing people.
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Affiliation(s)
- Jasmine D Johnson
- Division of Maternal-Fetal Medicine, Indiana University School of Medicine, 550 North University Bloulevard, Suite 2440, Indianapolis, IN 46202, USA.
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Skidmore KL, Drinkard J, Randall HM, Varrassi G, Shekoohi S, Kaye AD. The Significance of Equipment Availability and Anesthesia Educational Conferences to Decision-Making for EKG Lead V5 Abnormalities. Cureus 2024; 16:e53620. [PMID: 38449953 PMCID: PMC10915713 DOI: 10.7759/cureus.53620] [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] [Received: 01/12/2024] [Accepted: 02/04/2024] [Indexed: 03/08/2024] Open
Abstract
Introduction To predict postoperative myocardial infarction rates in patients who undergo noncardiac surgery, the Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management recommends assessment of brain natriuretic peptide (BNP) in certain patients. Serial troponins are measured if the BNP level is elevated. In certain cases, Revised Cardiac Risk Index (RCRI) alone does not perform well, for example, during vascular surgery. Cardiac events occur in 20% of all vascular surgery patients. The odds ratio for such events is 9.2 if ST segments were depressed by 1 mm intraoperatively (relative to the PR interval) within the first 48 hours postoperatively. Increasing the number of cables and pads from three to five for electrocardiogram (EKG) increases the sensitivity from around 30% to over 80% for ischemic events relative to a formal EKG stress test, and then the monitor continuously displays not only lead II but also lead V5. Methods Our hypothesis was that raising awareness about diagnostic and therapeutic options to reduce the risk of postoperative myocardial infarction would increase the use of five pads. We conducted open-ended surveys at six hospitals to assess the reasons for choosing three pads. In our university hospital practice, we measured a cross-sectional incidence of using three pads before and, once again, a month after an intervention during a single morning. Several resident conferences encouraged the use of five pads. Education included weekly lectures and informal discussions with other staff during surgery, demonstrating that using five pads allows interrogation of an entire 12-lead EKG. In comparison, three pads only allow viewing three leads. Results At baseline, only three pads were available in 96% of our 23 operating rooms. Five cables were available in eight of those surgeries, but two were taped off to the side. Surveys unveiled scarcity of equipment and, more importantly, disempowerment (i.e., knowing how to diagnose or when to treat ischemia). After several conferences, the prevalence of equipment availability of only three pads fell to 47%. Conclusions Education enumerated details of recognizing ischemic configurations of ST depression. Next, education revealed methods to interrupt the progression of ischemia to infarction such as elevated blood pressure and hematocrit, reducing heart rate, and calling a cardiology consultant if the anesthesiologist wishes to draw serial troponins. Barriers to implementing an enhanced recovery after surgery (ERAS) pathway began with a need for more access to manage stress tests or optimize blood pressure medications after a preoperative anesthesia evaluation. The intraoperative barrier was knowing what to do if ST depression occurs. Therefore, we began raising awareness by encouraging the addition of an element of a future ERAS pathway, adding a cost of only $1 to monitor lead V5. Future ERAS pathways can include preoperative stress tests and consults, as found in published guidelines.
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Affiliation(s)
- Kimberly L Skidmore
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Joseph Drinkard
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Henson M Randall
- Department of Medicine, Edward Via College of Osteopathic Medicine, Monroe, USA
| | | | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
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5
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Debbink MP, Stanhope KK, Hogue CJR. Racial and ethnic inequities in stillbirth in the US: Looking upstream to close the gap: Seminars in Perinatology. Semin Perinatol 2024; 48:151865. [PMID: 38220545 DOI: 10.1016/j.semperi.2023.151865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Though stillbirth rates in the United States improved over the previous decades, inequities in stillbirth by race and ethnicity have persisted nearly unchanged since data collection began. Black and Indigenous pregnant people face a two-fold greater risk of experiencing the devastating consequences of stillbirth compared to their White counterparts. Because race is a social rather than biological construct, inequities in stillbirth rates are a downstream consequence of structural, institutional, and interpersonal racism which shape a landscape of differential access to opportunities for health. These downstream consequences can include differences in the prevalence of chronic health conditions as well as structural differences in the quality of health care or healthy neighborhood conditions, each of which likely plays a role in racial and ethnic inequities in stillbirth. Research and intervention approaches that utilize an equity lens may identify ways to close gaps in stillbirth incidence or in responding to the health and socioemotional consequences of stillbirth. A community-engaged approach that incorporates experiential wisdom will be necessary to create a full picture of the causes and consequences of inequity in stillbirth outcomes. Investigators working in tandem with community partners, utilizing a combination of qualitative, quantitative, and implementation science approaches, may more fully elucidate the underpinnings of racial and ethnic inequities in stillbirth outcomes.
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Affiliation(s)
- Michelle P Debbink
- University of Utah Spencer Fox Eccles, School of Medicine Department of Obstetrics and Gynecology, Salt Lake City, UT.
| | - Kaitlyn K Stanhope
- Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, GA
| | - Carol J R Hogue
- Emory University Rollins School of Public Health, Department of Epidemiology, Atlanta, GA
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6
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Ansari JR, Yarmosh A, Michel G, Lyell D, Hedlin H, Cornfield DN, Carvalho B, Bateman BT. Intravenous Calcium to Decrease Blood Loss During Intrapartum Cesarean Delivery: A Randomized Controlled Trial. Obstet Gynecol 2024; 143:104-112. [PMID: 37917943 DOI: 10.1097/aog.0000000000005441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/21/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE To evaluate whether prophylactic administration of 1 g of intravenous calcium chloride after cord clamping reduces blood loss from uterine atony during intrapartum cesarean delivery. METHODS This single-center, block-randomized, placebo-controlled, double-blind superiority trial compared the effects of 1 g intravenous calcium chloride with those of saline placebo control on blood loss at cesarean delivery. Parturients at 34 or more weeks of gestation requiring intrapartum cesarean delivery after oxytocin exposure in labor were enrolled. Calcium or saline placebo was infused over 10 minutes beginning 1 minute after umbilical cord clamping in addition to standard care with oxytocin. The primary outcome was quantitative blood loss, analyzed by inverse Gaussian regression. Planned subgroup analysis excluded nonatonic bleeding, such as hysterotomy extension, arterial bleeding, and occult placenta accreta. We planned to enroll 120 patients to show a 200-mL reduction in quantitative blood loss in planned subgroup analysis, assuming up to 40% incidence of nonatonic bleeding (80% power, α<0.05). RESULTS From April 2022 through March 2023, 828 laboring parturients provided consent and 120 participants were enrolled. Median blood loss was 840 mL in patients allocated to calcium chloride (n=60) and 1,051 mL in patients allocated to placebo (n=60), which was not statistically different (mean reduction 211 mL, 95% CI -33 to 410). In the planned subgroup analysis (n=39 calcium and n=40 placebo), excluding cases of surgeon-documented nonatonic bleeding, calcium reduced quantitative blood loss by 356 mL (95% CI 159-515). Rates of reported side effects were similar between the two groups (38% calcium vs 42% placebo). CONCLUSION Prophylactic intravenous calcium chloride administered during intrapartum cesarean delivery after umbilical cord clamping did not significantly reduce blood loss in the primary analysis. However, in the planned subgroup analysis, calcium infusion significantly reduced blood loss by approximately 350 mL. These data suggest that this inexpensive and shelf-stable medication warrants future study as a novel treatment strategy to decrease postpartum hemorrhage, the leading global cause of maternal morbidity and mortality. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov , NCT05027048.
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Affiliation(s)
- Jessica R Ansari
- Department of Anesthesiology, Perioperative and Pain Medicine, the Department of Obstetrics and Gynecology, the Quantitative Sciences Unit, Department of Medicine, and the Department of Pediatrics, Stanford University, Stanford, California
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7
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Hales EDS, Ferketich AK, Klebanoff MA. The racial disparity of severe maternal morbidity across weeks of gestation: a cross-sectional analysis of the 2019 National Inpatient Sample. Am J Obstet Gynecol 2023:S0002-9378(23)02030-6. [PMID: 37979826 DOI: 10.1016/j.ajog.2023.11.1228] [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: 07/12/2023] [Revised: 11/03/2023] [Accepted: 11/09/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND Severe maternal morbidity is increasing in the United States. Black women experience the highest rates of severe maternal morbidity and also of preterm births, which are associated with severe maternal morbidity. The racial disparity of severe maternal morbidity across weeks of gestation has not been well-studied. OBJECTIVE This study aimed to evaluate differences in severe maternal morbidity between Black and White birthing people by week of gestation. Differences may indicate periods of pregnancy when Black women are particularly vulnerable to severe maternal morbidity and may require additional interventions. STUDY DESIGN This was a cross-sectional study using the National Inpatient Sample from 2019. We used International Classification of Diseases codes from Centers for Disease Control and Prevention guidelines to identify severe maternal morbidity from delivery hospitalizations. We examined the rates of severe maternal morbidity in Black vs White women by week of gestation to evaluate periods of pregnancy when Black women experience additional risks of severe maternal morbidity while adjusting for age, region, medical comorbidities, and Medicaid enrollment. Severe maternal morbidity was analyzed while both including and excluding cases for which blood transfusion was the only indicator of severe maternal morbidity. RESULTS Overall, Black birthing people had twice the rate of severe maternal morbidity births compared with White birthing people (2.7% vs 1.3%; P<.0001) and were more likely to deliver preterm (14.7% vs 9.4%; P<.0001). The racial disparity of severe maternal morbidity was present throughout all weeks of gestation, with the largest gap observed at extremely and moderately preterm gestations (22-33 weeks). Rates of severe maternal morbidity for Black women peaked at 22 to 33 weeks' gestation and were lowest at term (≥37 weeks). Black women had a greater proportion of severe maternal morbidity cases due to blood transfusion (68.3% vs 64.5%; P<.01) and acute renal failure (11.1% vs 8.5%; P<.001). CONCLUSION Black women experience a substantially higher rate of severe maternal morbidity at preterm gestations (22-36 weeks) in addition to higher rates of preterm delivery. Even when accounting for age, medical comorbidities, and social determinants, Black birthing people have higher odds of severe maternal morbidity throughout pregnancy.
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Affiliation(s)
- Emily D S Hales
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH
| | - Amy K Ferketich
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH
| | - Mark A Klebanoff
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH; Center for Perinatal Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH.
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Lord MG, Gould AJ, Clark MA, Rouse DJ, Lewkowitz AK. The AccuFlow sensor: a novel digital health tool to assess intrapartum blood loss at cesarean delivery. J Perinat Med 2023; 51:997-1005. [PMID: 37155696 DOI: 10.1515/jpm-2023-0101] [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] [Received: 03/05/2023] [Accepted: 04/02/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVES During obstetric hemorrhage, peripheral vasoconstriction maintains heart rate and blood pressure until compensatory mechanisms are overwhelmed and patients deteriorate rapidly. Real-time perfusion measurements could quantify vasoconstriction, improving early recognition of hemorrhage and facilitating early intervention to reduce morbidity and mortality. The AccuFlow device makes rapid, non-invasive, quantitative measurements of perfusion, but has not been studied for hemorrhage detection or used in surgical settings. This study evaluated feasibility, tolerability, and preliminary efficacy of the AccuFlow for assessment of blood loss at cesarean delivery (CD). METHODS In this pilot study, sensors were applied to the wrist, forearm, bicep, and chest wall of 25 patients undergoing scheduled CD. Postoperatively, sensors were removed and patients rated the AccuFlow and the standard anesthesia monitoring equipment on a validated comfort rating scale for wearable computers (CRS). Blood loss was estimated by the surgical team (EBL) and calculated from change in hematocrit, weight, and height (CBL). CRS scores were compared via Wilcoxon signed ranks tests. Coefficients of correlation between sensor readings and CBL, and between EBL and CBL, were compared using Fisher's R-to-z transformation. RESULTS There were no safety events; no participants requested device removal. CRS ratings of the AccuFlow and the standard monitoring equipment were similar (7.2 vs. 8.8, p=0.25). Change in wrist perfusion from delivery to dressing placement was more strongly correlated with CBL than was EBL (R=-0.48 vs. R=0.087, p=0.03). CONCLUSIONS The AccuFlow sensor is well-tolerated and shows promise in detecting intrapartum hemorrhage, though larger studies are needed.
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Affiliation(s)
- Megan G Lord
- Division of Maternal Fetal Medicine, Women & Infants Hospital of Rhode Island, Providence, RI, USA
- Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Melissa A Clark
- Division of Maternal Fetal Medicine, Women & Infants Hospital of Rhode Island, Providence, RI, USA
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Dwight J Rouse
- Division of Maternal Fetal Medicine, Women & Infants Hospital of Rhode Island, Providence, RI, USA
- Alpert Medical School of Brown University, Providence, RI, USA
| | - Adam K Lewkowitz
- Division of Maternal Fetal Medicine, Women & Infants Hospital of Rhode Island, Providence, RI, USA
- Alpert Medical School of Brown University, Providence, RI, USA
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Green CA, Johnson JD, McKenzie C, Stuebe AM. Standardized Order Sets Do Not Eliminate Racial or Ethnic Inequities in Postpartum Pain Management. Health Equity 2023; 7:685-691. [PMID: 37908404 PMCID: PMC10615045 DOI: 10.1089/heq.2022.0180] [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: 08/19/2023] [Indexed: 11/02/2023] Open
Abstract
Objective To quantify the extent to which a standardized pain management order set reduced racial and ethnic inequities in post-cesarean pain evaluation and management. Methods We conducted a retrospective cohort study to quantify racial and ethnic differences in pain evaluation and management before (July 2014-June 2016) and after implementation of a standardized post-cesarean order set (March 2017-February 2018). Electronic medical records were queried for pain scores >7/10, number of pain assessments, and opioid, nonsteroidal anti-inflammatory drug (NSAID), and acetaminophen doses. Outcomes were grouped into 0 to <24 and 24-48 h postpartum, and stratified by race/ethnicity (Hispanic, non-Hispanic Black [NHB], non-Hispanic White [NHW], Asian, and other), as documented in the electronic health record. Analyses included logistic regression for the categorical outcome of pain score >7 (severe pain), and linear regression, with propensity score adjustment. Main effect and interaction terms were used to calculate the difference-in-difference in pain process and outcome measures between the baseline and follow-up periods. Results After order set implementation (N=888), severe pain remained more common among NHB patients (% pain scores >7 NHW vs. NHB 0 to <24 h: 22% vs. 33%, p=0.003; 24-48 h: 26% vs. 40%, p<0.001). Among all patients, pain management processes changed after implementation of the order set, with overall fewer assessments, less Opioids, and more nonopioid analgesics. However, racial and ethnic inequities in a number of assessments and in treatment were unchanged (all p for interaction >0.05), with the exception of a modest increase in NSAID doses 24-48 h postpartum for Hispanic patients. Conclusion A standardized pain management order set reduced overall postpartum opioid use, but did not reduce racial and ethnic disparities in pain evaluation and management. Future work should investigate racial equity-focused education and interventions designed to eliminate disparities in pain management.
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Affiliation(s)
- Celeste A. Green
- Department of Obstetrics and Gynecology, University of Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jasmine D. Johnson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana, USA
| | - Christine McKenzie
- Department of Anesthesiology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA
| | - Alison M. Stuebe
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA
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Kheyfets A, Vitek K, Conklin C, Tu C, Larson E, Zera C, Iverson R, Reiff E, Healy A, Lauring J, Schoen C, Manganaro K, Pomerleau M, Glass B, Amutah-Onukagha N, Diop H, Meadows AR. Development of a Maternal Equity Safety Bundle to Eliminate Racial Inequities in Massachusetts. Obstet Gynecol 2023; 142:831-839. [PMID: 37734090 PMCID: PMC10510776 DOI: 10.1097/aog.0000000000005322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 04/10/2023] [Accepted: 04/20/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE The PNQIN (Perinatal-Neonatal Quality Improvement Network of Massachusetts) sought to adapt the Reduction of Peripartum Racial and Ethnic Disparities Conceptual Framework and Maternal Safety Consensus Bundle by selecting and defining measures to create a bundle to address maternal health inequities in Massachusetts. This study describes the process of developing consensus-based measures to implement the PNQIN Maternal Equity Bundle across Massachusetts hospitals participating in the Alliance for Innovation on Maternal Health Initiative. METHODS Our team used a mixed-methods approach to create the PNQIN Maternal Equity Bundle through consensus including a literature review, expert interviews, and a modified Delphi process to compile, define, and select measures to drive maternal equity-focused action. Stakeholders were identified by purposive and snowball sampling and included obstetrician-gynecologists, midwives, nurses, epidemiologists, and racial equity scholars. Dedoose 9.0 was used to complete an inductive analysis of interview transcripts. A modified Delphi method was used to reach consensus on recommendations and measures for the PNQIN Maternal Equity Bundle. RESULTS Twenty-five interviews were completed. Seven themes emerged, including the need for 1) data stratification by race, ethnicity and language; 2) performance of a readiness assessment; 3) culture shift toward equity; 4) inclusion of antiracism and bias training; 5) addressing challenges of nonacademic hospitals; 6) a life-course approach; and 7) selection of timing of implementation. Twenty initial quality measures (structure, process, and outcome) were identified through expert interviews. Group consensus supported 10 measures to be incorporated into the bundle. CONCLUSION Structure, process, and outcome quality measures were selected and defined for a maternal equity safety bundle that seeks to create an equity-focused infrastructure and equity-specific actions at birthing facilities. Implementation of an equity-focused safety bundle at birthing facilities may close racial gaps in maternal outcomes.
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Affiliation(s)
- Anna Kheyfets
- Perinatal-Neonatal Quality Improvement Network of Massachusetts, Tufts University School of Medicine, the Department of Obstetrics & Gynecology, Boston Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Brigham and Women's Hospital
- Department of Public Health and Community Medicine, Tufts University School of Medicine, and the Massachusetts Department of Health, Boston, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School-Baystate, Springfield, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School/UMass Memorial Health, Worcester, and the College of Nursing & Health Sciences, UMass Dartmouth, Dartmouth, Massachusetts; the Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Obstetrics & Gynecology, University of California San Diego Medical Center, San Diego, California
| | - Kali Vitek
- Perinatal-Neonatal Quality Improvement Network of Massachusetts, Tufts University School of Medicine, the Department of Obstetrics & Gynecology, Boston Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Brigham and Women's Hospital
- Department of Public Health and Community Medicine, Tufts University School of Medicine, and the Massachusetts Department of Health, Boston, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School-Baystate, Springfield, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School/UMass Memorial Health, Worcester, and the College of Nursing & Health Sciences, UMass Dartmouth, Dartmouth, Massachusetts; the Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Obstetrics & Gynecology, University of California San Diego Medical Center, San Diego, California
| | - Claire Conklin
- Perinatal-Neonatal Quality Improvement Network of Massachusetts, Tufts University School of Medicine, the Department of Obstetrics & Gynecology, Boston Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Brigham and Women's Hospital
- Department of Public Health and Community Medicine, Tufts University School of Medicine, and the Massachusetts Department of Health, Boston, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School-Baystate, Springfield, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School/UMass Memorial Health, Worcester, and the College of Nursing & Health Sciences, UMass Dartmouth, Dartmouth, Massachusetts; the Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Obstetrics & Gynecology, University of California San Diego Medical Center, San Diego, California
| | - Christianna Tu
- Perinatal-Neonatal Quality Improvement Network of Massachusetts, Tufts University School of Medicine, the Department of Obstetrics & Gynecology, Boston Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Brigham and Women's Hospital
- Department of Public Health and Community Medicine, Tufts University School of Medicine, and the Massachusetts Department of Health, Boston, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School-Baystate, Springfield, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School/UMass Memorial Health, Worcester, and the College of Nursing & Health Sciences, UMass Dartmouth, Dartmouth, Massachusetts; the Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Obstetrics & Gynecology, University of California San Diego Medical Center, San Diego, California
| | - Elysia Larson
- Perinatal-Neonatal Quality Improvement Network of Massachusetts, Tufts University School of Medicine, the Department of Obstetrics & Gynecology, Boston Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Brigham and Women's Hospital
- Department of Public Health and Community Medicine, Tufts University School of Medicine, and the Massachusetts Department of Health, Boston, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School-Baystate, Springfield, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School/UMass Memorial Health, Worcester, and the College of Nursing & Health Sciences, UMass Dartmouth, Dartmouth, Massachusetts; the Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Obstetrics & Gynecology, University of California San Diego Medical Center, San Diego, California
| | - Chloe Zera
- Perinatal-Neonatal Quality Improvement Network of Massachusetts, Tufts University School of Medicine, the Department of Obstetrics & Gynecology, Boston Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Brigham and Women's Hospital
- Department of Public Health and Community Medicine, Tufts University School of Medicine, and the Massachusetts Department of Health, Boston, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School-Baystate, Springfield, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School/UMass Memorial Health, Worcester, and the College of Nursing & Health Sciences, UMass Dartmouth, Dartmouth, Massachusetts; the Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Obstetrics & Gynecology, University of California San Diego Medical Center, San Diego, California
| | - Ronald Iverson
- Perinatal-Neonatal Quality Improvement Network of Massachusetts, Tufts University School of Medicine, the Department of Obstetrics & Gynecology, Boston Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Brigham and Women's Hospital
- Department of Public Health and Community Medicine, Tufts University School of Medicine, and the Massachusetts Department of Health, Boston, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School-Baystate, Springfield, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School/UMass Memorial Health, Worcester, and the College of Nursing & Health Sciences, UMass Dartmouth, Dartmouth, Massachusetts; the Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Obstetrics & Gynecology, University of California San Diego Medical Center, San Diego, California
| | - Emily Reiff
- Perinatal-Neonatal Quality Improvement Network of Massachusetts, Tufts University School of Medicine, the Department of Obstetrics & Gynecology, Boston Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Brigham and Women's Hospital
- Department of Public Health and Community Medicine, Tufts University School of Medicine, and the Massachusetts Department of Health, Boston, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School-Baystate, Springfield, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School/UMass Memorial Health, Worcester, and the College of Nursing & Health Sciences, UMass Dartmouth, Dartmouth, Massachusetts; the Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Obstetrics & Gynecology, University of California San Diego Medical Center, San Diego, California
| | - Andrew Healy
- Perinatal-Neonatal Quality Improvement Network of Massachusetts, Tufts University School of Medicine, the Department of Obstetrics & Gynecology, Boston Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Brigham and Women's Hospital
- Department of Public Health and Community Medicine, Tufts University School of Medicine, and the Massachusetts Department of Health, Boston, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School-Baystate, Springfield, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School/UMass Memorial Health, Worcester, and the College of Nursing & Health Sciences, UMass Dartmouth, Dartmouth, Massachusetts; the Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Obstetrics & Gynecology, University of California San Diego Medical Center, San Diego, California
| | - Julianne Lauring
- Perinatal-Neonatal Quality Improvement Network of Massachusetts, Tufts University School of Medicine, the Department of Obstetrics & Gynecology, Boston Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Brigham and Women's Hospital
- Department of Public Health and Community Medicine, Tufts University School of Medicine, and the Massachusetts Department of Health, Boston, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School-Baystate, Springfield, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School/UMass Memorial Health, Worcester, and the College of Nursing & Health Sciences, UMass Dartmouth, Dartmouth, Massachusetts; the Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Obstetrics & Gynecology, University of California San Diego Medical Center, San Diego, California
| | - Corina Schoen
- Perinatal-Neonatal Quality Improvement Network of Massachusetts, Tufts University School of Medicine, the Department of Obstetrics & Gynecology, Boston Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Brigham and Women's Hospital
- Department of Public Health and Community Medicine, Tufts University School of Medicine, and the Massachusetts Department of Health, Boston, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School-Baystate, Springfield, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School/UMass Memorial Health, Worcester, and the College of Nursing & Health Sciences, UMass Dartmouth, Dartmouth, Massachusetts; the Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Obstetrics & Gynecology, University of California San Diego Medical Center, San Diego, California
| | - Karen Manganaro
- Perinatal-Neonatal Quality Improvement Network of Massachusetts, Tufts University School of Medicine, the Department of Obstetrics & Gynecology, Boston Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Brigham and Women's Hospital
- Department of Public Health and Community Medicine, Tufts University School of Medicine, and the Massachusetts Department of Health, Boston, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School-Baystate, Springfield, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School/UMass Memorial Health, Worcester, and the College of Nursing & Health Sciences, UMass Dartmouth, Dartmouth, Massachusetts; the Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Obstetrics & Gynecology, University of California San Diego Medical Center, San Diego, California
| | - Mary Pomerleau
- Perinatal-Neonatal Quality Improvement Network of Massachusetts, Tufts University School of Medicine, the Department of Obstetrics & Gynecology, Boston Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Brigham and Women's Hospital
- Department of Public Health and Community Medicine, Tufts University School of Medicine, and the Massachusetts Department of Health, Boston, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School-Baystate, Springfield, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School/UMass Memorial Health, Worcester, and the College of Nursing & Health Sciences, UMass Dartmouth, Dartmouth, Massachusetts; the Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Obstetrics & Gynecology, University of California San Diego Medical Center, San Diego, California
| | - Bonnell Glass
- Perinatal-Neonatal Quality Improvement Network of Massachusetts, Tufts University School of Medicine, the Department of Obstetrics & Gynecology, Boston Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Brigham and Women's Hospital
- Department of Public Health and Community Medicine, Tufts University School of Medicine, and the Massachusetts Department of Health, Boston, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School-Baystate, Springfield, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School/UMass Memorial Health, Worcester, and the College of Nursing & Health Sciences, UMass Dartmouth, Dartmouth, Massachusetts; the Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Obstetrics & Gynecology, University of California San Diego Medical Center, San Diego, California
| | - Ndidiamaka Amutah-Onukagha
- Perinatal-Neonatal Quality Improvement Network of Massachusetts, Tufts University School of Medicine, the Department of Obstetrics & Gynecology, Boston Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Brigham and Women's Hospital
- Department of Public Health and Community Medicine, Tufts University School of Medicine, and the Massachusetts Department of Health, Boston, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School-Baystate, Springfield, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School/UMass Memorial Health, Worcester, and the College of Nursing & Health Sciences, UMass Dartmouth, Dartmouth, Massachusetts; the Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Obstetrics & Gynecology, University of California San Diego Medical Center, San Diego, California
| | - Hafsatou Diop
- Perinatal-Neonatal Quality Improvement Network of Massachusetts, Tufts University School of Medicine, the Department of Obstetrics & Gynecology, Boston Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Brigham and Women's Hospital
- Department of Public Health and Community Medicine, Tufts University School of Medicine, and the Massachusetts Department of Health, Boston, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School-Baystate, Springfield, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School/UMass Memorial Health, Worcester, and the College of Nursing & Health Sciences, UMass Dartmouth, Dartmouth, Massachusetts; the Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Obstetrics & Gynecology, University of California San Diego Medical Center, San Diego, California
| | - Audra R Meadows
- Perinatal-Neonatal Quality Improvement Network of Massachusetts, Tufts University School of Medicine, the Department of Obstetrics & Gynecology, Boston Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Brigham and Women's Hospital
- Department of Public Health and Community Medicine, Tufts University School of Medicine, and the Massachusetts Department of Health, Boston, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School-Baystate, Springfield, the Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, UMASS Chan Medical School/UMass Memorial Health, Worcester, and the College of Nursing & Health Sciences, UMass Dartmouth, Dartmouth, Massachusetts; the Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Obstetrics & Gynecology, University of California San Diego Medical Center, San Diego, California
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11
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Meadows AR, Byfield R, Bingham D, Diop H. Strategies to Promote Maternal Health Equity: The Role of Perinatal Quality Collaboratives. Obstet Gynecol 2023; 142:821-830. [PMID: 37678899 PMCID: PMC10510807 DOI: 10.1097/aog.0000000000005347] [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: 05/08/2023] [Revised: 06/15/2023] [Accepted: 06/22/2023] [Indexed: 09/09/2023]
Abstract
Perinatal quality improvement is a method to increase obstetric safety and promote health equity. Increasing trends of maternal deaths, life-threatening complications of pregnancy, and persistent racial inequities are unacceptable. This Narrative Review examines the role and strategies of perinatal quality initiatives and collaboratives to deliver safe and equitable maternity care and the evidence of demonstrated success. Key strategies to promote maternal equity through perinatal quality include communicating equity as a priority through leadership, leveraging data and enhancing surveillance, engaging in strategic partnerships, engaging community, educating clinicians, and implementing practice recommendations through collaboration.
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Affiliation(s)
- Audra R Meadows
- Department of Obstetrics, Gynecology, and Reproductive Sciences, UC San Diego School of Medicine, La Jolla, California; the Perinatal-Neonatal Quality Improvement Network of Massachusetts (PNQIN), and the Division of Maternal and Child Health Research and Analytics, Massachusetts Department of Health, Boston, and the Institute for Perinatal Quality Improvement, Quincy, Massachusetts
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12
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Hamm RF, Moniz MH, Wahid I, Breman RB, Callaghan-Koru JA. Implementation research priorities for addressing the maternal health crisis in the USA: results from a modified Delphi study among researchers. Implement Sci Commun 2023; 4:83. [PMID: 37480135 PMCID: PMC10360260 DOI: 10.1186/s43058-023-00461-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/21/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Maternal health outcomes in the USA are far worse than in peer nations. Increasing implementation research in maternity care is critical to addressing quality gaps and unwarranted variations in care. Implementation research priorities have not yet been defined or well represented in the plans for maternal health research investments in the USA. METHODS This descriptive study used a modified Delphi method to solicit and rank research priorities at the intersection of implementation science and maternal health through two sequential web-based surveys. A purposeful, yet broad sample of researchers with relevant subject matter knowledge was identified through searches of published articles and grant databases. The surveys addressed five implementation research areas in maternal health: (1) practices to prioritize for broader implementation, (2) practices to prioritize for de-implementation, (3) research questions about implementation determinants, (4) research questions about implementation strategies, and (5) research questions about methods/measures. RESULTS Of 160 eligible researchers, 82 (51.2%) agreed to participate. Participants were predominantly female (90%) and White (75%). Sixty completed at least one of two surveys. The practices that participants prioritized for broader implementation were improved postpartum care, perinatal and postpartum mood disorder screening and management, and standardized management of hypertensive disorders of pregnancy. For de-implementation, practices believed to be most impactful if removed from or reduced in maternity care were cesarean delivery for low-risk patients and routine discontinuation of all psychiatric medications during pregnancy. The top methodological priorities of participants were improving the extent to which implementation science frameworks and measures address equity and developing approaches for involving patients in implementation research. CONCLUSIONS Through a web-based Delphi exercise, we identified implementation research priorities that researchers consider to have the greatest potential to improve the quality of maternity care in the USA. This study also demonstrates the feasibility of using modified Delphi approaches to engage researchers in setting implementation research priorities within a clinical area.
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Affiliation(s)
- Rebecca F Hamm
- Maternal and Child Health Research Center, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Michelle H Moniz
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Inaya Wahid
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Rachel Blankstein Breman
- Department of Partnerships, Professional Education and Practice, School of Nursing, University of Maryland, Baltimore, MD, USA
| | - Jennifer A Callaghan-Koru
- Office of Community Health and Research, University of Arkansas for Medical Sciences, Springdale, AR, USA.
- Department of Obstetrics & Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
- Center for Implementation Research, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
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13
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Van Citters AD, Buus‐Frank ME, King JR, Seid M, Holthoff MM, Amin RS, Britto MT, Nelson EC, Marshall BC, Sabadosa KA. The Cystic Fibrosis Learning Network: A mixed methods evaluation of program goals, attributes, and impact. Learn Health Syst 2023; 7:e10356. [PMID: 37731865 PMCID: PMC10508326 DOI: 10.1002/lrh2.10356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/24/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction The Cystic Fibrosis (CF) Foundation sponsored the design, pilot testing, and implementation of the CF Learning Network (CFLN) to explore how the Foundation's Care Center Network (CCN) could become a learning health system. Six years after the design, the Foundation commissioned a formative mixed methods evaluation of the CFLN to assess: CFLN participants' understanding of program goals, attributes, and perceptions of current and future impact. Methods We performed semi-structured interviews with CFLN participants to identify perceived goals, attributes, and impact of the network. Following thematic analyses, we developed and distributed a survey to CFLN members and a matched sample of CCN programs to understand whether the themes were unique to the CFLN. Results Interviews with 24 CFLN participants were conducted. Interviewees identified the primary CFLN goal as improving outcomes for people living with CF, with secondary goals of providing training in quality improvement (QI), creating a learning community, engaging all stakeholders in improvement, and spreading best practices to the CCN. Project management, use of data, common QI methods, and the learning community were seen as critical to success. Survey responses were collected from 103 CFLN members and 25 CCN members. The data revealed that CFLN respondents were more likely than CCN respondents to connect with other CF programs, routinely use data for QI, and engage patient and family partners in QI. Conclusions Our study suggests that the CFLN provides value beyond that achieved by the CCN. Key questions remain about whether spread of the CFLN could improve outcomes for more people living with CF.
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Affiliation(s)
- Aricca D. Van Citters
- The Dartmouth Institute for Health Policy and Clinical PracticeGeisel School of MedicineLebanonNew HampshireUSA
| | - Madge E. Buus‐Frank
- The Dartmouth Institute for Health Policy and Clinical PracticeGeisel School of MedicineLebanonNew HampshireUSA
- Department of PediatricsDartmouth Health Children'sLebanonNew HampshireUSA
| | - Joel R. King
- The Dartmouth Institute for Health Policy and Clinical PracticeGeisel School of MedicineLebanonNew HampshireUSA
| | - Michael Seid
- Division of Pulmonary MedicineCincinnati Children's Hospital Medical Center and the University of Cincinnati College of MedicineCincinnatiOhioUSA
- James M Anderson Center for Health Systems ExcellenceCincinnati Children's Hospital Medical CenterCincinnatiOHUSA
| | - Megan M. Holthoff
- The Dartmouth Institute for Health Policy and Clinical PracticeGeisel School of MedicineLebanonNew HampshireUSA
| | - Raouf S. Amin
- Division of Pulmonary MedicineCincinnati Children's Hospital Medical Center and the University of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Maria T. Britto
- James M Anderson Center for Health Systems ExcellenceCincinnati Children's Hospital Medical CenterCincinnatiOHUSA
| | - Eugene C. Nelson
- The Dartmouth Institute for Health Policy and Clinical PracticeGeisel School of MedicineLebanonNew HampshireUSA
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Stierman EK, O'Brien BT, Stagg J, Ouk E, Alon N, Engineer LD, Fabiyi CA, Liu TM, Chew E, Benishek LE, Harding B, Terhorst RG, Latif A, Berenholtz SM, Mistry KB, Creanga AA. Statewide Perinatal Quality Improvement, Teamwork, and Communication Activities in Oklahoma and Texas. Qual Manag Health Care 2023; 32:177-188. [PMID: 36913770 PMCID: PMC10290572 DOI: 10.1097/qmh.0000000000000407] [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: 03/15/2023]
Abstract
BACKGROUND AND OBJECTIVE The purpose of this study was to describe statewide perinatal quality improvement (QI) activities, specifically implementation of Alliance for Innovation on Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units in Oklahoma and Texas. METHODS In January-February 2020, we conducted a survey of AIM-enrolled hospitals in Oklahoma (n = 35) and Texas (n = 120) to gather data on obstetric unit organization and QI processes. Data were linked to hospital characteristics information from the 2019 American Hospital Association survey and hospitals' maternity levels of care from state agencies. We generated descriptive statistics for each state and created an index to summarize adoption of QI processes. We fitted linear regression models to examine how this index varied by hospital characteristics and self-reported ratings for patient safety and AIM bundle implementation. RESULTS Most obstetric units had standardized clinical processes for obstetric hemorrhage (94% Oklahoma; 97% Texas), massive transfusion (94% Oklahoma; 97% Texas), and severe hypertension in pregnancy (97% Oklahoma; 80% Texas); regularly conducted simulation drills for obstetric emergencies (89% Oklahoma; 92% Texas); had multidisciplinary QI committees (61% Oklahoma; 83% Texas); and conducted debriefs after major obstetric complications (45% Oklahoma; 86% Texas). Few obstetric units offered recent staff training on teamwork and communication to their staff (6% Oklahoma; 22% Texas); those who did were more likely to employ specific strategies to facilitate communication, escalate concerns, and manage staff conflicts. Overall, adoption of QI processes was significantly higher in hospitals in urban than rural areas, teaching than nonteaching, offering higher levels of maternity care, with more staff per shift, and greater delivery volume (all P < .05). The QI adoption index scores were strongly associated with respondents' ratings for patient safety and implementation of maternal safety bundles (both P < .001). CONCLUSIONS Adoption of QI processes varies across obstetric units in Oklahoma and Texas, with implications for implementing future perinatal QI initiatives. Notably, findings highlight the need to reinforce support for rural obstetric units, which often face greater barriers to implementing patient safety and QI processes than urban units.
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Affiliation(s)
- Elizabeth K Stierman
- Departments of International Health (Drs Stierman and Creanga) and Health Policy and Management (Drs Engineer and Berenholtz), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Oklahoma Perinatal Quality Improvement Collaborative, Oklahoma City, (Mss O'Brien and Ouk); The University of Oklahoma Health Sciences Center, Oklahoma City (Mss O'Brien and Ouk); Community Health Improvement Division, Texas Department of State Health Services, Austin (Ms Stagg); Alliance for Innovation on Maternal Health, American College of Obstetricians and Gynecologists, Washington, District of Columbia (Ms Alon); Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine, Baltimore, Maryland (Drs Engineer, Benishek, Latif, and Berenholtz, Ms Liu, and Mr Terhorst); Departments of Anesthesiology and Critical Care Medicine (Drs Engineer, Benishek, Latif, and Berenholtz) and Gynecology and Obstetrics (Dr Creanga), Johns Hopkins School of Medicine, Baltimore, Maryland; and Agency for Healthcare Research and Quality, Rockville, Maryland (Drs Fabiyi and Mistry and Mss Chew and Harding)
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15
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Menda N, Edwards E. Measuring Equity for Quality Improvement. Clin Perinatol 2023; 50:531-543. [PMID: 37201995 DOI: 10.1016/j.clp.2023.01.010] [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: 05/20/2023]
Abstract
Applying an equity lens to quality improvement (QI) by collecting, reviewing, and using data that measure health disparities helps identify whether QI interventions improve outcomes evenly and equally across the population or have a greater impact in an advantaged or disadvantaged group. Methodological issues inherent in measuring disparities include appropriately selecting data sources; ensuring reliability and validity of equity data; choosing a suitable comparison group; and understanding between-group variation. The integration and utilization of QI techniques to promote equity is dependent on meaningful measurement to develop targeted interventions and provide a means of ongoing real-time assessment.
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Affiliation(s)
- Nina Menda
- Department of Pediatrics, University of Wisconsin, 202 South Park Street, McConnell Hall, 4th Floor, Madison, WI 53715, USA.
| | - Erika Edwards
- Vermont Oxford Network, Burlington, VT 05401, USA; Department of Pediatrics, Robert Larner, MD, College of Medicine, University of Vermont, Burlington, VT 05405, USA; Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, University of Vermont, Burlington, VT 05405, USA
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Kern-Goldberger AR, Srinivas SK. Variation as Evidence of Preventability: Research and Policy Implications of State Differences in Severe Maternal Morbidity Rates. Obstet Gynecol 2023; 141:875-876. [PMID: 37023449 DOI: 10.1097/aog.0000000000005162] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Affiliation(s)
- Adina R Kern-Goldberger
- Adina R. Kern-Goldberger is from the Division of Maternal-Fetal Medicine, Women's Health Institute, Cleveland Clinic Foundation, and the Department of Quantitative Health Sciences, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio. Sindhu K. Srinivas is from the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania;
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Federspiel JJ, Eke AC, Eppes CS. Postpartum hemorrhage protocols and benchmarks: improving care through standardization. Am J Obstet Gynecol MFM 2023; 5:100740. [PMID: 36058518 PMCID: PMC9941009 DOI: 10.1016/j.ajogmf.2022.100740] [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: 05/13/2022] [Revised: 08/11/2022] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
Abstract
Postpartum hemorrhage remains a leading cause of maternal morbidity and mortality in the United States. Several state maternal morbidity and mortality committees have reviewed areas of opportunity concerning postpartum hemorrhage management and found that common patterns include delays in recognition and response to hemorrhage. Hospital systems and state perinatal quality collaboratives have found that comprehensive, interdisciplinary response to postpartum hemorrhage care improves patient outcomes and, in some instances, reduces racial disparities. A key component of this focus involves the implementation of stage-based hemorrhage protocols for postpartum hemorrhage management. Stage-based hemorrhage protocols are designed to reduce delays in the diagnosis and management and avoid the pitfalls of cognitive biases. These protocols are complex, and their effectiveness is tied to the quality of their implementation. Systematic benchmarking and development of quality metrics for adherence to postpartum hemorrhage bundles would be expected to improve clinical outcomes, but evidence regarding the effectiveness of this practice in the literature is limited. Here, key features of stage-based interventions and evidence regarding the use of quality metrics for postpartum hemorrhage protocol adherence have been outlined.
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Affiliation(s)
- Jerome J Federspiel
- From the Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (Dr Federspiel).
| | - Ahizechukwu C Eke
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr Eke); Division of Clinical Pharmacology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr Eke)
| | - Catherine S Eppes
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Dr Eppes)
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Lord MG, Calderon JA, Ahmadzia HK, Pacheco LD. Emerging technology for early detection and management of postpartum hemorrhage to prevent morbidity. Am J Obstet Gynecol MFM 2023; 5:100742. [PMID: 36075527 DOI: 10.1016/j.ajogmf.2022.100742] [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: 04/29/2022] [Revised: 08/28/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
Abstract
Despite advances in hemorrhage detection and management, postpartum hemorrhage remains the single leading cause of maternal death worldwide. Within the United States, hemorrhage is the leading cause of maternal death on the day of delivery and within the first week after delivery. Blood transfusion after hemorrhage represents a large proportion of severe maternal morbidity during and after delivery. Blood loss during delivery has historically been assessed visually by inspecting soiled pads, linens, and laparotomy sponges. These methods underestimate the volume of blood loss by as much as 40%, becoming increasingly inaccurate as blood loss increases. Young, healthy obstetrical patients compensate for blood loss via peripheral vasoconstriction, maintaining heart rate and blood pressure in a normal range until over 1 L of blood has been lost. A significant decrease in blood pressure along with marked tachycardia (>120 bpm) may not be seen until 30% to 40% of blood volume has been lost, or 2.0 to 2.6 L in a healthy term pregnant patient, after which the patient may rapidly decompensate. In resource-poor settings especially, the narrow window between the emergence of significant vital sign abnormalities and clinical decompensation may prove catastrophic. Once hemorrhage is detected, decisions regarding blood product transfusion are routinely made on the basis of inaccurate estimates of blood loss, placing patients at risk of underresuscitation (increasing the risk of hemorrhagic shock and end-organ damage) or overresuscitation (increasing the risk of transfusion reaction, fluid overload, and alloimmunization). We will review novel technologies that have emerged to assist both in the early and accurate detection of postpartum hemorrhage and in decisions regarding blood product transfusion.
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Affiliation(s)
- Megan G Lord
- Division of Maternal-Fetal Medicine, Women & Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence, RI (Dr Lord).
| | - Joaquin A Calderon
- Division of Maternal-Fetal Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC (Drs Calderon and Ahmadzia)
| | - Homa K Ahmadzia
- Division of Maternal-Fetal Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC (Drs Calderon and Ahmadzia)
| | - Luis D Pacheco
- Divisions of Maternal-Fetal Medicine and Surgical Critical Care, University of Texas Medical Branch, Galveston, TX (Dr Pacheco)
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Federspiel JJ, Kucirka LM, Mallampati DP, Wheeler SM, Menard MK, Hughes BL, Quist-Nelson J, Meng ML. For better care we need better data: towards a national obstetrics registry. Am J Obstet Gynecol MFM 2023; 5:100787. [PMID: 36404523 PMCID: PMC10065844 DOI: 10.1016/j.ajogmf.2022.100787] [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: 08/30/2022] [Revised: 09/29/2022] [Accepted: 10/20/2022] [Indexed: 11/05/2022]
Abstract
Unacceptably high rates of severe maternal morbidity and mortality in the United States and stark racial disparities in outcomes are generating efforts to improve both research capacity and quality improvement in obstetrical care. Comprehensive, high-quality datasets on which to build these efforts are crucial to the success of obstetrical quality improvement efforts. However, existing data sources in obstetrics have notable limitations. Other medical and surgical specialties have addressed similar challenges through the creation of national registries, and we argue that obstetrics must take the same approach to improve outcomes. In this article, we summarized the current availability and limitations of large-scale data in obstetrics research and compared the data with registries developed in other specialties. Moreover, we have outlined the guiding principles for the development of a national obstetrics registry and have proposed future directions.
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Affiliation(s)
- Jerome J Federspiel
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (Drs Federspiel, Wheeler, and Hughes).
| | - Lauren M Kucirka
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Durham, NC (Drs Kucirka, Mallampati, Menard, and Quist-Nelson)
| | - Divya P Mallampati
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Durham, NC (Drs Kucirka, Mallampati, Menard, and Quist-Nelson)
| | - Sarahn M Wheeler
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (Drs Federspiel, Wheeler, and Hughes)
| | - M Kathyrn Menard
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Durham, NC (Drs Kucirka, Mallampati, Menard, and Quist-Nelson)
| | - Brenna L Hughes
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (Drs Federspiel, Wheeler, and Hughes)
| | - Johanna Quist-Nelson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Durham, NC (Drs Kucirka, Mallampati, Menard, and Quist-Nelson)
| | - Marie-Louise Meng
- Division of Women's Anesthesiology, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA (Dr Meng)
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Erickson EN, Krol KM, Perkeybile AM, Connelly JJ, Myatt L. Oxytocin receptor single nucleotide polymorphism predicts atony-related postpartum hemorrhage. BMC Pregnancy Childbirth 2022; 22:884. [PMID: 36447139 PMCID: PMC9706912 DOI: 10.1186/s12884-022-05205-w] [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] [Received: 08/23/2022] [Accepted: 11/10/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Postpartum hemorrhage remains a key contributor to overall maternal morbidity in the United States. Current clinical assessment methods used to predict postpartum hemorrhage are unable to prospectively identify about 40% of hemorrhage cases. Oxytocin is a first-line pharmaceutical for preventing and treating postpartum hemorrhage, which acts through oxytocin receptors on uterine myocytes. Existing research indicates that oxytocin function is subject to variation, influenced in part by differences in the DNA sequence within the oxytocin receptor gene. One variant, rs53576, has been shown to be associated with variable responses to exogenous oxytocin when administered during psychological research studies. How this variant may influence myometrial oxytocin response in the setting of third stage labor has not been studied. We tested for differences in the frequency of the oxytocin receptor genotype at rs53576 in relationship to the severity of blood loss among a sample of individuals who experienced vaginal birth. METHODS A case-control prospective design was used to enroll 119 postpartum participants who underwent vaginal birth who were at least 37 weeks of gestation. Cases were defined by either a 1000 mL or greater blood loss or instances of heavier bleeding where parturients were given additional uterotonic treatment due to uterine atony. Controls were matched to cases on primiparity and labor induction status. Genotype was measured from a maternal blood sample obtained during the 2nd postpartum month from 95 participants. Statistical analysis included bivariate tests and generalized linear and Poisson regression modeling. RESULTS The distribution of the genotype across the sample of 95 participants was 40% GG (n = 38), 50.5% AG (n = 48) and 9.5% AA (n = 9). Blood loss of 1000 mL or greater occurred at a rate of 7.9% for GG, 12.5% for AG and 55.6% for AA participants (p = 0.005). Multivariable models demonstrated A-carriers (versus GG) had 275.2 mL higher blood loss (95% CI 96.9-453.4, p < 0.01) controlling for parity, intrapartum oxytocin, self-reported ancestry, active management of third stage or genital tract lacerations. Furthermore, A-carrier individuals had a 79% higher risk for needing at least one second-line treatment (RR = 1.79, 95% CI = 1.08-2.95) controlling for covariates. Interaction models revealed that A-carriers who required no oxytocin for labor stimulation experienced 371.4 mL greater blood loss (95% CI 196.6-546.2 mL). CONCLUSIONS We provide evidence of a risk allele in the oxytocin receptor gene that may be involved in the development of postpartum hemorrhage among participants undergoing vaginal birth, particularly among those with fewer risk factors. The findings, if reproducible, could be useful in studying pharmacogenomic strategies for predicting, preventing or treating postpartum hemorrhage.
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Affiliation(s)
- Elise N. Erickson
- grid.134563.60000 0001 2168 186XPresent Address: University of Arizona, Tucson, AZ USA ,grid.5288.70000 0000 9758 5690Oregon Health and Science University, OR Portland, USA
| | - Kathleen M. Krol
- grid.27755.320000 0000 9136 933XUniversity of Virginia, Charlottesville, VA USA
| | | | - Jessica J. Connelly
- grid.27755.320000 0000 9136 933XUniversity of Virginia, Charlottesville, VA USA
| | - Leslie Myatt
- grid.5288.70000 0000 9758 5690Oregon Health and Science University, OR Portland, USA
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Profit J, Edwards EM, Pursley D. Getting to health equity in NICU care in the USA and beyond. Arch Dis Child Fetal Neonatal Ed 2022:archdischild-2021-323533. [PMID: 36379698 DOI: 10.1136/archdischild-2021-323533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 10/26/2022] [Indexed: 11/17/2022]
Abstract
Differences in race/ethnicity, gender, income and other social factors have long been associated with disparities in health, illness and premature death. Although the terms 'health differences' and 'health disparities' are often used interchangeably, health disparities has recently been reserved to describe worse health in socially disadvantaged populations, particularly members of disadvantaged racial/ethnic groups and the poor within a racial/ethnic group. Infants receiving disparate care based on race/ethnicity, immigration status, language proficiency, or social class may be discomforting to healthcare workers who dedicate their lives to care for these patients. Recent literature, however, has documented differences in neonatal intensive care unit (NICU) care quality that have contributed to racial and ethnic differences in mortality and significant morbidity. We examine the within-NICU and between-NICU mechanisms of disparate care and recommend approaches to address these disparities.
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Affiliation(s)
- Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California, USA .,California Perinatal Quality Care Collaborative, Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Erika M Edwards
- Vermont Oxford Network, Burlington, Vermont, USA.,Department of Pediatrics, Robert Larner MD College of Medicine, University of Vermont, Burlington, Vermont, USA.,Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, University of Vermont, Burlington, Vermont, USA
| | - DeWayne Pursley
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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22
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Hamm RF, Howell E, James A, Faizon R, Bloemer T, Cohen J, Srinivas SK. Implementation and outcomes of a system-wide women’s health ‘team goal’ to reduce maternal morbidity for black women: a prospective quality improvement study. BMJ Open Qual 2022; 11:bmjoq-2022-002061. [PMID: 36384880 PMCID: PMC9670954 DOI: 10.1136/bmjoq-2022-002061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/01/2022] [Indexed: 11/17/2022] Open
Abstract
ObjectiveIn response to the unacceptable racial disparities in US obstetric outcomes, our health system established a formal goal to reduce maternal morbidity for black women. Here, we describe our process for meeting this equity-focused goal in the context of diverse implementation climates at 5 inpatient sites.Study designTo meet the system goal, we established a collaborative of multidisciplinary, site-based teams. The validated 18-question Implementation Climate Scale (ICS) was distributed to site clinicians at baseline. Sites focused on haemorrhage, performing case reviews of black women meeting morbidity criteria. Comparing cases by site, site-specific areas for improvement in haemorrhage risk assessment, prevention and management emerged. Evidence-based practices (EBPs) were then selected, tailored and implemented by site. Monthly system-wide team meetings included (1) metric tracking and (2) site presentations with discussions around barriers/facilitators to EBP implementation. Maternal morbidity rates among black women were compared the year before goal development (1 July 2019–30 June 2020) to the year after (1 July 2020–30 June 2021).ResultsMean ICS scores for inpatient obstetric units differed by site (p=0.005), with climates more supportive of implementation at urban/academic hospitals. In response to case reviews, sites reported implementing 2 to 8 EBPs to meet the goal. Despite different ICS scores, this process was associated with significant reductions in maternal morbidity for black women from pregoal to postgoal development overall and at sites 1, 2 and 3, with non-statistically significant reductions at sites 4 and 5 (overall: −29.4% reduction, p<0.001).ConclusionsA health system goal of reducing maternal morbidity for black women led to a data-driven, collaborative model for implementing site-tailored interventions. If health systems prioritise equity-focused goals, sites can be supported in implementing EBPs that improve care.
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Affiliation(s)
- Rebecca Feldman Hamm
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Elizabeth Howell
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Abike James
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Robert Faizon
- Department of Obstetrics & Gynecology, Lancaster General Health, Lancaster, Pennsylvania, USA
| | - Tina Bloemer
- Department of Obstetrics & Gynecology, Penn Medicine Princeton Medical Center, Plainsboro, New Jersey, USA
| | - Jennifer Cohen
- Department of Neonatology, Chester County Hospital, West Chester, Pennsylvania, USA
| | - Sindhu K Srinivas
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Prochaska M, Salcedo J, Berry G, Meltzer D. Racial differences in red blood cell transfusion in hospitalized patients with anemia. Transfusion 2022; 62:1519-1526. [PMID: 35657149 PMCID: PMC9357128 DOI: 10.1111/trf.16935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/28/2022] [Accepted: 04/29/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Guidelines recommend transfusion of red blood cells (RBC's) when a hospitalized patient's hemoglobin (Hb) drops below a restrictive transfusion threshold, either at 7 or 8 g. Hospitals have implemented transfusion policies to encourage compliance with guidelines and reduce variation in transfusion practice. However, variation in transfusion practice remains. The purpose of this study was to examine whether there is variation in the receipt of transfusion by patient race. METHODS Hospitalized general medicine patients with anemia (Hb < 10 g/dL) were eligible. Chi-squared tests were used to compare the percent of patients receiving a transfusion by race overall and within strata of their nadir Hb. Linear regression was used to test the association between a patient's race, their nadir Hb, receipt of an RBC transfusion, and the number of units transfused. RESULTS Four thousand nine hundred and fifty-one patients consented, including 1363 (28%) who received a transfusion. 71% of patients were African American, 25% were White, and 4% were Other Race. Overall African Americans were less likely to be transfused compared to Whites (25% vs. 30%, p < .01), and within Hb strata below a Nadir Hb of 9 g/dL (Hb 8.0-8.9 g/dL 1% vs. 7%, p < .01; 7.0-7.9 g/dL 15% vs. 28%, p < .01; <7 g/dL 80% vs. 86%, p < .01). African Americans also received fewer units of RBC's (β = -.17, p < .01) overall and at lower Hb levels (β = .14, p < .01) compared to Whites. DISCUSSION The Hb level at which patients are transfused at and the total number of RBC units received during hospitalization differ by patient race.
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Affiliation(s)
- Micah Prochaska
- Section of Hospital Medicine, Department of MedicineThe University of ChicagoChicagoIllinois
| | - Jorge Salcedo
- UCLA David Geffen School of MedicineLos AngelesCaliforniaUSA
| | - Grace Berry
- Section of Hospital Medicine, Department of MedicineThe University of ChicagoChicagoIllinois
| | - David Meltzer
- Section of Hospital Medicine, Department of MedicineThe University of ChicagoChicagoIllinois
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How Can We Get to Equitable and Effective Postpartum Pain Control? Clin Obstet Gynecol 2022; 65:577-587. [PMID: 35703219 DOI: 10.1097/grf.0000000000000731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Postpartum pain is common, yet patient experiences and clinical management varies greatly. In the United States, pain-related expectations and principles of adequate pain management have been framed within established norms of Western clinical medicine and a biomedical understanding of disease processes. Unfortunately, this positioning of postpartum pain and the corresponding coping strategies and pain treatments is situated within cultural biases and systemic racism. This paper summarizes the history and existing literature that examines racial inequities in pain management to propose guiding themes and suggestions for innovation. This work is critical for advancing ethical practice and establishing more effective care for all patients.
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Abstract
PURPOSE OF REVIEW Healthcare disparities are health differences that adversely affect disadvantaged populations. In the United States, research shows that women of color, in particular Black and Hispanic women and their offspring, experience disproportionately higher mortality, severe maternal morbidity, and neonatal morbidity and mortality. This review highlights recent population health sciences and comparative effectiveness research that discuss racial and ethnic disparities in maternal and perinatal outcomes. RECENT FINDINGS Epidemiological research confirms the presence of maternal and neonatal disparities in national and multistate database analysis. These disparities are associated with geographical variations, hospital characteristics and practice patterns, and patient demographics and comorbidities. Proposed solutions include expanded perinatal insurance coverage, increased maternal healthcare public funding, and quality improvement initiatives/efforts that promote healthcare protocols and practice standardization. SUMMARY Obstetrical healthcare disparities are persistent, prevalent, and complex and are associated with systemic racism and social determinants of health. Some of the excess disparity gap can be explained through community-, hospital-, provider-, and patient-level factors. Providers and healthcare organizations should be mindful of these disparities and strive to promote healthcare justice and patient equity. Several solutions provide promise in closing this gap, but much effort remains.
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Perinatal quality collaboratives and birth equity. Curr Opin Anaesthesiol 2022; 35:299-305. [PMID: 35671016 DOI: 10.1097/aco.0000000000001143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss how state perinatal quality collaboratives are addressing birth equity to reduce disparities in maternal morbidity and mortality. RECENT FINDING Perinatal quality collaboratives are adopting core practices to advance birth equity, reduce disparities and confront racism and bias in obstetric care including securing leadership commitments to equity, providing education on the causes of inequities and mitigation strategies, collecting accurate race/ethnicity data, addressing social determinants of health, and integrating patient and community knowledge, experiences, and narratives in the quality improvement work. SUMMARY Inequities in maternal morbidity and mortality particularly affecting Black birthing people are driven by racism, inequities in the social determinants of health, and variations in care practices and quality. Perinatal quality collaboratives are an important resource for driving improvement changes to mitigate these factors and improve outcomes. VIDEO ABSTRACT Mason CL, Collier CH, Penny SC. Perinatal Quality Collaboratives and Birth Equity. Produced by CLMB Productions for use in this publication. January 10, 2022, http://links.lww.com/COAN/A86.
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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.
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Bączkowska M, Kosińska-Kaczyńska K, Zgliczyńska M, Brawura-Biskupski-Samaha R, Rebizant B, Ciebiera M. Epidemiology, Risk Factors, and Perinatal Outcomes of Placental Abruption-Detailed Annual Data and Clinical Perspectives from Polish Tertiary Center. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:5148. [PMID: 35564543 PMCID: PMC9101673 DOI: 10.3390/ijerph19095148] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/16/2022] [Accepted: 04/21/2022] [Indexed: 12/10/2022]
Abstract
Placental abruption (PA) is a separation of the placenta from the uterine wall occurring with the fetus still present in the uterine cavity. It contributes to numerous neonatal and maternal complications, increasing morbidity and mortality. We conducted a retrospective study at a tertiary perinatal care center, which included 2210 cases of labor that took place in 2015 with a PA occurrence of 0.7%. No maternal or fetal death during delivery was reported in this period. The identified PA risk factors were uterine malformations, pPROM, placenta previa spectrum, and oligohydramnios. The significant maternal PA complications identified were maternal anemia, uterine rupture, and HELLP syndrome. Preterm delivery occurred significantly more often in the PA group, and the number of weeks of pregnancy and the birth weight at delivery were both significantly lower in the PA group. PA is a relatively rare perinatal complication with very serious consequences, and it still lacks effective prophylaxis and treatment. Despite its rare occurrence, each center should develop a certain strategy for dealing with this pathology or predicting which patients are at risk. Much work is still needed to ensure the proper care of the mother and the baby in this life-threatening condition.
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Affiliation(s)
| | | | | | | | | | - Michał Ciebiera
- Center of Postgraduate Medical Education, Second Department of Obstetrics and Gynecology, 01-813 Warsaw, Poland; (M.B.); (K.K.-K.); (M.Z.); (R.B.-B.-S.); (B.R.)
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Davidson C, Denning S, Thorp K, Tyer-Viola L, Belfort M, Sangi-Haghpeykar H, Gandhi M. Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity. BMJ Qual Saf 2022; 31:670-678. [PMID: 35428682 DOI: 10.1136/bmjqs-2021-014225] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 03/01/2022] [Indexed: 11/03/2022]
Abstract
The objective of this study was to evaluate the impact of quality improvement (QI) and patient safety initiatives and data disaggregation on racial disparities in severe maternal morbidity from hemorrhage (SMM-H).Our hospital began monitoring and reporting on SMM-overall and SMM-H rates in 2018 using administrative data. In March 2019, we began stratifying data by race and ethnicity and noted a disparity in rates, with non-Hispanic Black women having the highest SMM rates. The data was presented as run charts at monthly department meetings. During this time, our hospital implemented several QI and patient safety initiatives around obstetric hemorrhage and used the stratified data to inform guideline development to reduce racial disparity. The initiatives included implementation of a hemorrhage patient safety bundle and in-depth case reviews of adverse patient outcomes with a health equity focus. We then retrospectively analyzed our data. Our outcome of interest was SMM-H prior to data stratification (pre-intervention: June 2018-February 2019) as compared to after data stratification (post-intervention: March 2019-June 2020).During our study time period, there were 13,659 deliveries: 37% Hispanic, 35% White, 20% Black, 7% Asian and 1% Other. Pre-intervention, there was a statistically significant difference between Black and White women for SMM-H rates (p<0.001). This disparity was no longer significant post-intervention (p=0.138). The rate of SMM-H in Black women decreased from 45.5% to 31.6% (p=0.011).Our findings suggest that QI and patient safety efforts that incorporate race and ethnicity data stratification to identify disparities and use the information to target interventions have the potential to reduce disparities in SMM.
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Affiliation(s)
- Christina Davidson
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Stacie Denning
- Department of Obstetrics and Gynecology, Texas Children's Hospital, Houston, Texas, USA
| | - Kristin Thorp
- Department of Obstetrics and Gynecology, Texas Children's Hospital, Houston, Texas, USA
| | - Lynda Tyer-Viola
- Department of Obstetrics and Gynecology, Texas Children's Hospital, Houston, Texas, USA
| | - Michael Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Haleh Sangi-Haghpeykar
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Manisha Gandhi
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
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Greenberg MB, Gandhi M, Davidson C, Carter EB. Society for Maternal-Fetal Medicine Consult Series #62: Best practices in equitable care delivery-Addressing systemic racism and other social determinants of health as causes of obstetrical disparities. Am J Obstet Gynecol 2022; 227:B44-B59. [PMID: 35378098 DOI: 10.1016/j.ajog.2022.04.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The Centers for Disease Control and Prevention define social determinants of health as "the conditions in the places where people live, learn, work, and play" that can affect health outcomes. Systemic racism is a root cause of the power and wealth imbalances that affect social determinants of health, creating disproportionate rates of comorbidities and adverse outcomes in the communities of racial and ethnic minority groups. Focusing primarily on disparities between Black and White individuals born in the United States, this document reviews the effects of social determinants of health and systemic racism on reproductive health outcomes and recommends multilevel approaches to mitigate disparities in obstetrical outcomes.
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Liu J, Jing W, Liu M. Risk management of pregnant women and the associated low maternal mortality from 2008-2017 in China: a national longitude study. BMC Health Serv Res 2022; 22:335. [PMID: 35287680 PMCID: PMC8920427 DOI: 10.1186/s12913-022-07721-z] [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: 08/19/2021] [Accepted: 03/03/2022] [Indexed: 11/30/2022] Open
Abstract
Background Reducing maternal mortality is one of the key targets of the Sustainable Development Goals (SDGs). In response to the impact of increased birth rate on maternal and child safety following the implementation of the two-child policy in 2013, the Chinese government implemented the risk management strategy (namely Five Strategies for Maternal and Newborn Safety, FSMNS) to reduce maternal mortality ratio (MMR). We aimed to analyze the changes in the proportion of pregnant women at high risk screened before and after the implementation of the risk management strategy and the association with maternal mortality during the two-child policy era in China. Methods We conducted a nationwide longitudinal study using data obtained from the National Statistical Yearbook and the National Health Statistics Yearbook for all 31 provinces from 2008–2017 to assess and analyze the changes in the proportion of pregnant women at high risk screened before (2008–2013) and after (2014–2017) the implementation of the risk management strategy during the two-child policy era. We used generalized estimating equation (GEE) models to analyze the relationship between the proportion of pregnant women at high risk and MMR after controlling for sociodemographic factors, health resources, and other maternal healthcare factors. Results In the past decade, the number of livebirths in China increased by 32.3%, from 13.3 million in 2008 to 17.6 million in 2017. The median proportion of pregnant women at high risk in 31 provinces increased by 64.8%, from 14.87% in 2008 to 24.50% in 2017. The annual rate of increase in the median proportion of pregnant women at high risk after the implementation of risk management (1.33%) was higher than that before the implementation (0.74%). The median MMR in China decreased by 39.6%, from 21.7 per 100,000 livebirths in 2008 to 13.1 per 100,000 livebirths in 2017. The univariate GEE models showed that MMR decreased by 7.9% per year from 2008–2017 (cRR 0.92, 95% CI 0.91–0.93), and the proportion of pregnant women at high risk was negatively correlated with MMR (cRR 0.97, 95%CI 0.94–0.99; p = 0.001). In the multivariate GEE models, after adjusting for confounders, the proportion of pregnant women at high risk remained negatively correlated with MMR. In the subgroup analysis, the association of MMR with GDP per capita and government health expenditure per capita existed only prior to the implementation of risk management; while high MMR was associated with a low proportion of pregnant women at high risk after the implementation of risk management. Conclusion The national risk management strategy contributed to the stable decline of MMR in China during the two-child policy era. Further attention should be focused on pregnant women in China’s central and western regions to ensure reaching SDGs targets and the ‘Healthy China Plan’ by 2030. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07721-z.
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Affiliation(s)
- Jue Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Haidian District, No.38, Xueyuan Road, Beijing, 100191, China.,National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, No.38, Xueyuan Road, Haidian District, Beijing, 100191, China.,Peking University Institute for Global Health and Development, Peking University, No.5 Yiheyuan Road Haidian District, Beijing, 100871, People's Republic of China
| | - Wenzhan Jing
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Haidian District, No.38, Xueyuan Road, Beijing, 100191, China
| | - Min Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Haidian District, No.38, Xueyuan Road, Beijing, 100191, China.
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Suresh S, Amegashie C, Patel E, Nieman KM, Rana S. Racial Disparities in Diagnosis, Management, and Outcomes in Preeclampsia. Curr Hypertens Rep 2022; 24:87-93. [PMID: 35254590 DOI: 10.1007/s11906-022-01172-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE OF THE REVIEW Racial disparities are prevalent in many aspects of obstetric care in the USA. Non-Hispanic black women have a higher prevalence of the diagnosis of hypertensive disorders of pregnancy in addition to associated morbidity and mortality. The purpose of this review is to review current data regarding racial disparities in the diagnosis and management of hypertensive disorders of pregnancy. RECENT FINDINGS Diagnosis of hypertensive disorders of pregnancy is more common among non-Hispanic black women even after adjustment for comorbidities. Furthermore, prevalence of severe morbidity among those with hypertensive disorders of pregnancy is increased in non-Hispanic black women, including cardiovascular events related. Proposed management solutions include quality improvement initiatives, telehealth, and strategies to reduce both structural racism and implicit bias. Racial disparities exist in both diagnosis and management of hypertensive disorders of pregnancy; further innovative work is needed to reduce these disparities.
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Affiliation(s)
- Sunitha Suresh
- Division of Maternal Fetal Medicine/Department of Obstetrics and Gynecology, University of Chicago Medicine, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | | | - Easha Patel
- Division of Maternal Fetal Medicine/Department of Obstetrics and Gynecology, University of Chicago Medicine, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Kristin M Nieman
- Division of Maternal Fetal Medicine/Department of Obstetrics and Gynecology, University of Chicago Medicine, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Sarosh Rana
- Division of Maternal Fetal Medicine/Department of Obstetrics and Gynecology, University of Chicago Medicine, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA.
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James AH, Federspiel JJ, Ahmadzia HK. Disparities in obstetric hemorrhage outcomes. Res Pract Thromb Haemost 2022; 6:e12656. [PMID: 35146237 PMCID: PMC8818495 DOI: 10.1002/rth2.12656] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 11/02/2021] [Accepted: 11/07/2021] [Indexed: 11/07/2022] Open
Abstract
Both the maternal and fetal outcomes of pregnancy vary greatly according to a pregnant woman’s community and her condition. The most devastating outcome is the death of a mother. In 2017, there were ≈295,000 maternal deaths globally with dramatic differences in maternal mortality based on geographic region, country, and women’s underlying conditions. Worldwide, the leading cause of maternal death is hemorrhage, comprising 94% of maternal deaths, with most cases occurring in low‐ or middle‐income countries. Whether a hemorrhage originates from inside the uterus (80%‐90%), from lacerations or incisions (10%‐20%), or from an underlying coagulopathy (<1%), an acute acquired coagulopathy will evolve unless the hemorrhage is controlled. In low‐ or middle‐income countries, the full range of resources to control hemorrhage is not available, but besides the usual obstetric measures, blood availability, hemostatic medication, and hematologic expertise are necessary to save mothers’ lives. Hemostasis and thrombosis experts can address the disparities in obstetric hemorrhage outcomes not only as providers but as consultants, researchers, and advocates.
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Affiliation(s)
- Andra H. James
- Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine Duke University Durham North Carolina USA
| | - Jerome J. Federspiel
- Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine Duke University Durham North Carolina USA
| | - Homa K. Ahmadzia
- Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine The George Washington University Washington District of Columbia USA
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Gleason JL, Grewal J, Chen Z, Cernich AN, Grantz KL. Risk of Adverse Maternal Outcomes in Pregnant Women With Disabilities. JAMA Netw Open 2021; 4:e2138414. [PMID: 34910153 PMCID: PMC8674748 DOI: 10.1001/jamanetworkopen.2021.38414] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Women with disabilities have a higher risk of preterm birth, gestational diabetes, preeclampsia, and cesarean delivery; however, their risk of other obstetric interventions, adverse maternal outcomes, and clinical indications for increased cesarean delivery is unclear. OBJECTIVE To evaluate risk of a range of obstetric interventions and adverse maternal outcomes, including severe maternal morbidities (SMM) and mortality, among women with and without disabilities. DESIGN, SETTING, AND PARTICIPANTS The Consortium on Safe Labor was a retrospective cohort that included comprehensive medical chart review for deliveries between January 2002 and January 2008. Data were collected from 12 clinical sites, which included 19 hospitals across the United States. This secondary analysis was conducted in February to July 2021. EXPOSURES Using International Classification of Diseases, Ninth Revision, codes and a validated algorithm to define disability, participants were classified as having physical, intellectual, sensory, or any disability, and compared with women with no documented disability. MAIN OUTCOMES AND MEASURES The relative risk (RR) of 23 obstetric interventions and adverse maternal outcomes, including SMM and mortality, was evaluated. RESULTS Of the 223 385 women in the study, 9206 (4.1%) were Asian or Pacific Islander, 50 235 (22.5%) were Black, 39 039 (17.5%) were Hispanic, and 110 443 (49.4%) were White, with a mean (SD) age of 27.6 (6.2) years. There were 2074 (0.9%) women with disability and 221 311 (99.1%) without. Among women with disabilities, 1733 (83.5%) were physical, 91 (4.4%) were intellectual, and 250 (12.1%) were sensory. Compared with women with no disability, women with disabilities had higher risk of gestational diabetes, placenta previa, premature rupture of membranes, preterm premature rupture of membranes, and postpartum fever as well as maternal death (adjusted relative risk [aRR], 11.19; 95% CI, 2.40-52.19) and individual SMMs: severe preeclampsia/eclampsia (aRR, 2.15; 95% CI, 1.80-2.56), hemorrhage (aRR, 1.27; 95% CI, 1.09-1.49), and fever (aRR, 1.32; 95% CI, 1.03-1.67), with the highest risk observed for thromboembolism (aRR, 6.08; 95% CI, 4.03-9.16), cardiovascular events (aRR, 4.02; 95% CI, 2.87-5.63), and infection (aRR, 2.69; 95% CI, 1.97-3.67). Women with any disability also had higher risk of interventions, including oxytocin augmentation, operative vaginal delivery, and cesarean delivery (aRR, 1.33; 95% CI, 1.25-1.42), with the cesarean indication less likely to be medically indicated (aRR, 0.79; 95% CI, 0.70-0.89). Risk of adverse outcomes and interventions remained consistent across disability categories. CONCLUSIONS AND RELEVANCE In this study, women with physical, intellectual, and sensory disability during pregnancy were at higher risk of adverse outcomes, including a broad range of SMM and maternal mortality.
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Affiliation(s)
- Jessica L. Gleason
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Jagteshwar Grewal
- Office of the Director, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Zhen Chen
- Biostatistics and Bioinformatics Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Alison N. Cernich
- Office of the Director, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Katherine L. Grantz
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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Reassuringly expensive - A commentary on obstetric emergency training in high-resource settings. Best Pract Res Clin Obstet Gynaecol 2021; 80:14-24. [PMID: 34893439 DOI: 10.1016/j.bpobgyn.2021.11.009] [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: 07/25/2021] [Revised: 11/05/2021] [Accepted: 11/15/2021] [Indexed: 11/22/2022]
Abstract
The pathophysiologic origins of obstetrical emergencies are complicated and may well be influenced by events prior to conception. Such problems are not likely to be resolved soon, and in the meantime, high-resource countries simply cannot afford to divert more and more money to litigation and the costs of preventable morbidities for either mother or child. It is long past time we tackled these acute care problems where most first occur-the Maternity unit. It is reasonable to ask whether hospitals (and society at large) are getting what they believe they are buying. Training to satisfy a regulation without improving patient outcomes functionally erects one more barrier to the pursuit of optimal patient outcomes. Why then continue squandering limited resources and precious lives if current hospital training is not improving outcomes? In this monograph, I focus on training programs for the management of obstetrical emergencies.
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Stratton P. Standardizing care of those at great risk: the importance of sickle cell in pregnancy practice guidelines. Br J Haematol 2021; 194:950-953. [PMID: 34409588 DOI: 10.1111/bjh.17667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 06/08/2021] [Accepted: 06/08/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Pamela Stratton
- Office of the Clinical Director, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
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Reducing Perinatal Health Disparities by Placing Equity at the Heart of Performance Improvement. Obstet Gynecol 2021; 137:481-485. [PMID: 33543902 DOI: 10.1097/aog.0000000000004283] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/03/2020] [Indexed: 11/26/2022]
Abstract
Multiple studies have demonstrated that low income and Black women in the United States are more likely to suffer from severe maternal morbidity and mortality during childbirth, even when accounting for the site of service. Structural racism, social determinants of health, and personally mediated racism are factors that may play a role. Assessing them is, therefore, critical in the attempt to deliver safe and equitable health care, which is a fundamental charge of performance-improvement committees. We argue that, for performance-improvement committees to fulfill their mandate, they must include equity as an organizing principle. A low rate of adverse outcomes in the overall population served by a hospital is not sufficient if, when stratified by race, a particular group is found to have rates above acceptable limits. In this piece we outline the process by which those charged with assuring optimal quality in departments of obstetrics and gynecology can include equity in their portfolio. This is a key step in moving beyond the recognition that disparities exist and toward a consideration of the specific ways in which inequity contributes to morbidity, and then to implementing steps to mitigate its effects.
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Roset Bahmanyar E, Out HJ, van Duin M. Women and babies are dying from inertia: a collaborative framework for obstetrical drug development is urgently needed. Am J Obstet Gynecol 2021; 225:43-50. [PMID: 34215353 DOI: 10.1016/j.ajog.2021.03.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/10/2021] [Accepted: 03/18/2021] [Indexed: 12/16/2022]
Abstract
Obstetrical complications, often referred to as the "great obstetrical syndromes," are among the most common global causes of mortality and morbidity in young women and their infants. However, treatments for these syndromes are underdeveloped compared with other fields of medicine and are urgently needed. This current paucity of treatments for obstetrical complications is a reflection of the challenges of drug development in pregnancy. The appetite of pharmaceutical companies to invest in research for obstetrical syndromes is generally reduced by concerns for maternal, fetal, and infant safety, poor definition, and high-risk regulatory paths toward product approval. Notably, drug candidates require large investments for development with an unguaranteed return on investment. Furthermore, the discovery of promising drug candidates is hampered by a poor understanding of the pathophysiology of obstetrical syndromes and their uniqueness to human pregnancies. This limits translational extrapolation and de-risking strategies in preclinical studies, as available for other medical areas, compounded with limited fetal safety monitoring to capture early prenatal adverse reactions. In addition, the ethical review committees are reluctant to approve the inclusion of pregnant women in trials, and in the absence of regulatory guidance in obstetrics, clinical development programs are subject to unpredictable regulatory paths. To develop effective and safe drugs for pregnancy complications, substantial commitment, and investment in research for innovative therapies are needed in parallel with the creation of an enabling ethical, legislative, and guidance framework. Solutions are proposed to enable stakeholders to work with a common set of expectations to facilitate progress in this medical discipline. Addressing this significant unmet need to advance maternal and possibly perinatal health requires the involvement of all stakeholders and specifically patients, couples, and clinicians facing pregnancy complications in the dearth of appropriate therapies. This paper focused on the key pharmaceutical research and development challenges to achieve effective and safe treatments for obstetrical syndromes.
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Hamm RF, Iriye BK, Srinivas SK. Implementation Science is Imperative to the Optimization of Obstetric Care. Am J Perinatol 2021; 38:643-648. [PMID: 33321535 PMCID: PMC9268067 DOI: 10.1055/s-0040-1721728] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
In an effort aimed at improving outcomes, obstetric teams have enacted comprehensive care bundles and other clinical tools. Yet, these practices have had limited degrees of success on a national scale. Implementation science aims to bridge the divide between the development of evidence-based interventions and their real-world utilization. This emerging field takes into account key stakeholders at the clinician, institution, and health policy levels. Implementation science evaluates how well an intervention is or can be delivered, to whom, in which context, and how it may be up-scaled and sustained. Other medical disciplines have embraced these concepts with success. The frameworks and theories of implementation science can and should be incorporated into both obstetric research and practice. By doing so, we can increase widespread and timely adoption of evidence and further our common goal of decreasing maternal morbidity and mortality. KEY POINTS: · Evidence-based practices have been implemented in obstetrics with variable success.. · Implementation science aims to bridge the divide between the development of evidence-based interventions and their real-world utilization.. · The methodologies of implementation science may be helpful to obstetric research and practice..
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Affiliation(s)
- Rebecca F. Hamm
- Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | - Sindhu K. Srinivas
- Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Parker MG, Hwang SS. Quality improvement approaches to reduce racial/ethnic disparities in the neonatal intensive care unit. Semin Perinatol 2021; 45:151412. [PMID: 33865628 DOI: 10.1016/j.semperi.2021.151412] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Inequities in neonatal care quality and outcomes persist. Current models of neonatal quality improvement (QI) typically involve implementation of standardized approaches to clinical care that seek to provide consistent care to all infants and their families, which may neglect to account for the unique needs of diverse patient populations. Current approaches often fail to track outcome and process measures by important social disparity metrics, such as race/ethnicity and primary language. Despite these shortcomings, use of a QI structure has tremendous potential to address disparities in neonatal care. Crucial components of a QI approach to achieve health equity include: (1) Identifying equity goals from the inception of a project; (2) Inclusion of diverse family members on multidisciplinary teams; (3) Tracking outcome and process measures according to disparity metrics; and (4) Conducting interventions that preferentially address barriers of high-risk social groups. Hospital-system commitment to diversity and inclusion in the healthcare work force, recognition of the impact of unconscious provider bias and advocacy in the greater public health setting are needed to address underlying social inequities that impact neonatal care quality.
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Affiliation(s)
- Margaret G Parker
- Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, 88 E Newton St, Vose Hall, 3rd Floor, Boston, MA 02118, United States.
| | - Sunah S Hwang
- Department of Pediatrics, Colorado Children's Hospital, University of Colorado School of Medicine, United States
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Stratton P, Gorodetsky E, Clayton J. Pregnant in the United States in the COVID-19 pandemic: A collision of crises we cannot ignore. J Natl Med Assoc 2021; 113:499-503. [PMID: 33883068 PMCID: PMC8542420 DOI: 10.1016/j.jnma.2021.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/02/2021] [Accepted: 03/21/2021] [Indexed: 01/20/2023]
Abstract
NO abstract intended, Introduction is listed here The COVID-19 pandemic and call for social justice is occurring when the United States, unlike its peer countries, has already experienced a steady 20-year rise in maternal morbidity and mortality with pregnant women today facing a 50 percent higher risk of mortality than their mothers. 1 Most vulnerable are women of color, black and American Indian/Alaska Native women, who have experienced longstanding disparities in access to and quality of healthcare and may begin pregnancy with hypertension, diabetes, and obesity, complications known to be more common in women enduring segregation. 2–4 Initially, the race-related health disparities and resultant disproportionately higher rates of COVID-19 cases and mortality in indigenous communities and black, latinx, or other communities of color were mistakenly considered innate racial differences. More recently, these higher rates have been attributed to underlying social, structural, and environmental determinants of health including resource inequities, inadequate housing, and occupational and environmental hazards that result in greater exposure to and less protection from COVID-19. 5,6 Augmented by the added physiologic stress of pregnancy, these comorbidities and disparities compound the risk of pregnancy-associated cardiomyopathy, thromboembolism, and hemorrhage, often resulting in lasting physical and mental health consequences.
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Affiliation(s)
- Pamela Stratton
- Scientific Consulting Group, Inc., Gaithersburg, MD, United States; Office of the Clinical Director, Intramural Research Program, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States.
| | - Elena Gorodetsky
- Office of Research on Women's Health, National Institutes of Health, Bethesda, MD, United States
| | - Janine Clayton
- Office of Research on Women's Health, National Institutes of Health, Bethesda, MD, United States
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Sutton MY, Anachebe NF, Lee R, Skanes H. Racial and Ethnic Disparities in Reproductive Health Services and Outcomes, 2020. Obstet Gynecol 2021; 137:225-233. [PMID: 33416284 PMCID: PMC7813444 DOI: 10.1097/aog.0000000000004224] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/15/2020] [Accepted: 10/29/2020] [Indexed: 11/26/2022]
Abstract
Racial and ethnic disparities in women's health have existed for decades, despite efforts to strengthen women's reproductive health access and utilization. Recent guidance by the American College of Obstetricians and Gynecologists (ACOG) underscores the often unacknowledged and unmeasured role of racial bias and systemic racial injustice in reproductive health disparities and highlights a renewed commitment to eliminating them. Reaching health equity requires an understanding of current racial-ethnic gaps in reproductive health and a concerted effort to develop and implement strategies to close gaps. We summarized national data for several reproductive health measures, such as contraceptive use, Pap tests, mammograms, maternal mortality, and unintended pregnancies, by race-ethnicity to inform health-equity strategies. Studies were retrieved by systematically searching the PubMed (2010-2020) electronic database to identify most recently published national estimates by race-ethnicity (non-Hispanic Black or African American, Hispanic or Latinx, and non-Hispanic White women). Disparities were found in each reproductive health category. We describe relevant components of the Affordable Care Act (ACA) and the Preventing Maternal Deaths Act, which can help to further strengthen reproductive health care, close gaps in services and outcomes, and decrease racial-ethnic reproductive health disparities. Owing to continued diminishment of certain components of the ACA, to optimally reach reproductive health equity, comprehensive health insurance coverage is vital. Strengthening policy-level strategies, along with ACOG's heightened commitment to eliminating racial disparities in women's health by confronting bias and racism, can strengthen actions toward reproductive health equity.
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Affiliation(s)
- Madeline Y Sutton
- Department of Obstetrics and Gynecology, Morehouse School of Medicine, Atlanta Georgia
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Kennedy HP, Balaam MC, Dahlen H, Declercq E, de Jonge A, Downe S, Ellwood D, Homer CSE, Sandall J, Vedam S, Wolfe I. The role of midwifery and other international insights for maternity care in the United States: An analysis of four countries. Birth 2020; 47:332-345. [PMID: 33124095 DOI: 10.1111/birt.12504] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 08/12/2020] [Accepted: 08/24/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND The United States (US) spends more on health care than any other high-resource country. Despite this, their maternal and newborn outcomes are worse than all other countries with similar levels of economic development. Our purpose was to describe maternal and newborn outcomes and organization of care in four high-resource countries (Australia, Canada, the Netherlands, and United Kingdom) with consistently better outcomes and lower health care costs, and to identify opportunities for emulation and improvement in the United States. METHOD We examined resources that described health care organization and financing, provider types, birth settings, national, clinical guidelines, health care policies, surveillance data, and information for consumers. We conducted interviews with country stakeholders representing the disciplines of obstetrics, midwifery, pediatrics, neonatology, epidemiology, sociology, political science, public health, and health services. The results of the analysis were compared and contrasted with the US maternity system. RESULTS The four countries had lower rates of maternal mortality, low birthweight, and newborn and infant death than the United States. Five commonalities were identified as follows: (1) affordable/ accessible health care, (2) a maternity workforce that emphasized midwifery care and interprofessional collaboration, (3) respectful care and maternal autonomy, (4) evidence-based guidelines on place of birth, and (5) national data collections systems. CONCLUSIONS The findings reveal marked differences in the other countries compared to the United States. It is critical to consider the evidence for improved maternal and newborn outcomes with different models of care and to examine US cultural and structural failures that are leading to unacceptable and substandard maternal and infant outcomes.
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Affiliation(s)
| | - Marie-Clare Balaam
- School of Community Health and Midwifery, Research in Childbirth and Health Unit (REACH) Group, University of Central Lancashire, Lancashire, UK
| | - Hannah Dahlen
- School of Nursing and Midwifery, Western Sydney University, Sydney, NSW, Australia
| | - Eugene Declercq
- Department of Obstetrics & Gynecology, School of Public Health, Boston University, Boston, MA, USA
| | - Ank de Jonge
- Amsterdam University Medical Center, VU University Amsterdam, Amsterdam, The Netherlands.,Department of Midwifery Science, AVAG/Amsterdam Public Health, Amsterdam, The Netherlands
| | - Soo Downe
- School of Community Health and Midwifery, Research in Childbirth and Health Unit (REACH) Group, University of Central Lancashire, Lancashire, UK
| | - David Ellwood
- Department of Obstetrics & Gynaecology, Griffith University School of Medicine, Brisbane, QLD, Australia
| | - Caroline S E Homer
- Burnet Institute, Global Women's & Newborns Working Group, Melbourne, VIC, Australia
| | | | - Saraswathi Vedam
- Birth Place Lab, University of British Columbia, Vancouver, BC, Canada
| | - Ingrid Wolfe
- Kings College London, London, UK.,Children & Young People's Health Partnership, London, UK.,Child Public Health at Evelina London Children's Healthcare, London, UK
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Eppes CS, Han SB, Haddock AJ, Buckler AG, Davidson CM, Hollier LM. Enhancing Obstetric Safety Through Best Practices. J Womens Health (Larchmt) 2020; 30:265-269. [PMID: 33227226 PMCID: PMC8020520 DOI: 10.1089/jwh.2020.8878] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The pregnancy-related mortality rate in the US exceeds that of other developed nations and is marked by significant disparities in outcome by race. This article reviews the evidence supporting the implementation of a variety of best practices designed to reduce maternal mortality. Evidence from maternal mortality review committees suggests that delays in diagnosis, delays in initiation of treatment and use of ineffective treatments contribute to preventable cases of maternal death. We review several protocols for maternal warning signs that have been used successfully to facilitate early identification and intervention. Care bundles, a collection of best practices, have been developed and implemented to address several maternal emergencies. We review the evidence that supports reduction in adverse outcomes with consistent implementation of obstetric hemorrhage and severe hypertension bundles in a collaborative, team-based setting. The article concludes with suggestions for the future.
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Affiliation(s)
- Catherine Squire Eppes
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Sacha B Han
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Alison J Haddock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - A Gretchen Buckler
- Office of Research on Women's Health, National Institutes of Health, Bethesda, Maryland, USA
| | - Christina M Davidson
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Lisa M Hollier
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
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Abstract
Postpartum hemorrhage is a leading cause of severe maternal morbidity and mortality worldwide and the United States. While the rates of maternal mortality attributable to hemorrhage are declining, severe maternal morbidity continues to be a growing problem. Efforts in recent years to more appropriately identify patients at risk, define significant hemorrhage, quantify blood loss, and standardize approaches to care in pregnancy and postpartum have led to an increasing preventability of PPH. We aim to review the most current recommendation for the prevention and effective management of obstetric hemorrhage.
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Affiliation(s)
- Veronica Gonzalez-Brown
- Division Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Patrick Schneider
- Division Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH, USA.
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Lankford A, Chow J, Hendrickson E, Jung MS, Kodali B, Malinow A, Goetzinger K, Mazzeffi M. Five-year trends in maternal cardiac arrest in Maryland: 2013-2017. J Matern Fetal Neonatal Med 2020; 35:2984-2987. [PMID: 32900253 DOI: 10.1080/14767058.2020.1813710] [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: 10/23/2022]
Abstract
BACKGROUND The United States (US) maternal mortality rate (MMR) continues to increase. Until recently, the MMR in Maryland (MD) was consistently higher than the national average. Maternal cardiac arrest (MCA) is a rare condition, but can lead to devastating consequences. The incidence of MCA in the US is approximately 6-8 per 100,000 deliveries. To our knowledge there is no contemporary review of MCA in MD. Our primary aim was to determine the incidence of MCA in MD over a 5-year period. Secondary aims were to explore the causes of MCA, as well as characterize maternal and fetal survival. MATERIALS AND METHODS Maternal cardiac arrests in Maryland were identified using diagnostic codes and a statewide administrative database for the fiscal years 2013 through 2017. MCA incidence and mortality rates were compared with previously reported national data from 1998 to 2011. Demographic characteristics, medical co-morbidities, obstetric complications, mode of delivery, and fetal outcomes were collected for all patients. The apparent cause of MCA was determined for each patient. Complications and procedures performed in MCAs were also recorded. RESULTS In MD, 36 of 47 acute care hospitals provided maternity care. There were 32 cases of MCA in 332,483 deliveries, an estimated incidence rate of 10 per 100,000 deliveries (95% CI = 5-18). The most common apparent cause of MCA was hemorrhage. Maternal survival was 59.4%, while fetal survival was 93.8%. No significant differences were observed in MCA by age group. The incidence of MCA was significantly higher among non-Caucasian patients (24/177,727) when compared to Caucasian patients (8/154,732)(p =.01). DISCUSSION Maternal cardiac arrest in Maryland appears to be comparable to the US average, with similar maternal survival rates. Non-Caucasian patients appear to have a disproportionately high rate of these complications. While maternal mortality is high for MCA, fetal survival is excellent. Continued efforts and attention are needed to prevent MCA in underserved minorities and treat postpartum hemorrhage, the leading contributor to MCA over the past decade.
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Affiliation(s)
- Allison Lankford
- Department of Obstetrics and Gynecology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jonathan Chow
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Myung Sun Jung
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bhavani Kodali
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrew Malinow
- Department of Obstetrics and Gynecology, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Katherine Goetzinger
- Department of Obstetrics and Gynecology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
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