Amy Balbierz

Association Between Hospital-Level Obstetric Quality Indicators and Maternal and Neonatal Morbidity

IMPORTANCE In an effort to improve the quality of care, several obstetric-specific quality measures are now monitored and publicly reported. The extent to which these measures are associated with maternal and neonatal morbidity is not known. OBJECTIVE To examine whether 2 Joint Commission obstetric quality indicators are associated with maternal and neonatal morbidity. DESIGN, SETTING, AND PARTICIPANTS Population-based observational study using linked New York City discharge and birth certificate data sets from 2010. All delivery hospitalizations were identified and 2 perinatal quality measures were calculated (elective, nonmedically indicated deliveries at 37 or more weeks of gestation and before 39 weeks of gestation; cesarean delivery performed in low-risk mothers). Published algorithms were used to identify severe maternal morbidity (delivery associated with a life-threatening complication or performance of a lifesaving procedure) and morbidity in term newborns without anomalies (births associated with complications such as birth trauma, hypoxia, and prolonged length of stay). Mixed-effects logistic regression models were used to examine the association between maternal morbidity, neonatal morbidity, and hospital-level quality measures while risk-adjusting for patient sociodemographic and clinical characteristics. MAIN OUTCOMES AND MEASURES Individual- and hospital-level maternal and neonatal morbidity. RESULTS Severe maternal morbidity occurred among 2372 of 115,742 deliveries (2.4%), and neonatal morbidity occurred among 8057 of 103,416 term newborns without anomalies (7.8%). Rates for elective deliveries performed before 39 weeks of gestation ranged from 15.5 to 41.9 per 100 deliveries among 41 hospitals. There were 11.7 to 39.3 cesarean deliveries per 100 deliveries performed in low-risk mothers. Maternal morbidity ranged from 0.9 to 5.7 mothers with complications per 100 deliveries and neonatal morbidity from 3.1 to 21.3 neonates with complications per 100 births. The maternal quality indicators elective delivery before 39 weeks of gestation and cesarean delivery performed in low-risk mothers were not associated with severe maternal complications (risk ratio [RR], 1.00 [95% CI, 0.98-1.02] and RR, 0.99 [95% CI, 0.96-1.01], respectively) or neonatal morbidity (RR, 0.99 [95% CI, 0.97-1.01] and RR, 1.01 [95% CI, 0.99-1.03], respectively). CONCLUSIONS AND RELEVANCE Rates for the quality indicators elective delivery before 39 weeks of gestation and cesarean delivery performed in low-risk mothers varied widely in New York City hospitals, as did rates of maternal and neonatal complications. However, there were no correlations between the quality indicator rates and maternal and neonatal morbidity. Current quality indicators may not be sufficiently comprehensive for guiding quality improvement in obstetric care.

Black-white differences in severe maternal morbidity and site of care.

BACKGROUND For every maternal death, >100 women experience severe maternal morbidity, which is a life-threatening diagnosis, or undergo a life-saving procedure during their delivery hospitalization. Similar to racial/ethnic disparities in maternal death, black women are more likely to experience severe maternal morbidity than white women. Site of care has received attention as a mechanism to explain disparities in other areas of medicine. Data indicate that black women receive care in a concentrated set of hospitals and that these hospitals appear to provide lower quality of care. Whether racial differences in the site of delivery contribute to observed black-white disparities in severe maternal morbidity rates is unknown. OBJECTIVE The purpose of this study was to determine whether hospitals with high proportions of black deliveries have higher severe maternal morbidity and whether such differences contribute to overall black-white disparities in severe maternal morbidity. STUDY DESIGN We used a published algorithm to identify cases of severe maternal morbidity during deliveries in the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project for 2010 and 2011. We ranked hospitals by their proportion of black deliveries into high black-serving (top 5%), medium black-serving (5% to 25% range), and low black-serving hospitals. We analyzed the risks of severe maternal morbidity for black and white women by hospital black-serving status using logistic regressions that were adjusted for patient characteristics, comorbidities, hospital characteristics, and within-hospital clustering. We then derived adjusted rates from these models. RESULTS Seventy-four percent of black deliveries occurred at high and medium black-serving hospitals. Overall, severe maternal morbidity occurred more frequently among black than white women (25.8 vs 11.8 per 1000 deliveries, respectively; P < .001); after adjustment for the distribution of patient characteristics and comorbidities, this differential declined but remained elevated (18.8 vs 13.3 per 1000 deliveries, respectively; P < .001). Women who delivered in high and medium black-serving hospitals had elevated rates of severe maternal morbidity rates compared with those in low black-serving hospitals in unadjusted (29.4 and 19.4 vs 12.2 per 1000 deliveries, respectively; P < .001) and adjusted analyses (17.3 and 16.5 vs 13.5 per 1000 deliveries, respectively; P < .001). Black women who delivered at high black-serving hospitals had the highest risk of poor outcomes. CONCLUSION Most black deliveries occur in a concentrated set of hospitals, and these hospitals have higher severe maternal morbidity rates. Targeting quality improvement efforts at these hospitals may improve care for all deliveries and disproportionately impact care for black women.

An intervention to extend breastfeeding among black and Latina mothers after delivery.

OBJECTIVE The purpose of this study was to compare breastfeeding duration in mothers after delivery who were assigned randomly to a behavioral educational intervention vs enhanced usual care. STUDY DESIGN We conducted a randomized trial. Self-identified black and Latina mothers early after delivery were assigned randomly to receive a behavioral educational intervention or enhanced usual care. The 2-step intervention aimed to prepare and educate mothers about postpartum symptoms and experiences (including tips on breastfeeding and breast/nipple pain) and to bolster social support and self-management skills. Enhanced usual care participants received a list of community resources and received a 2-week control call. Intention-to-treat analyses examined breastfeeding duration (measured in weeks) for up to 6 months of observation. This study was registered with clinicaltrial.gov (NCT01312883). RESULTS Five hundred forty mothers were assigned randomly to the intervention (n = 270) vs control subjects (n = 270). Mean age was 28 years (range, 18-46 years); 62% of the women were Latina, and 38% were black. Baseline sociodemographic, clinical, psychosocial, and breastfeeding characteristics were similar among intervention vs control subjects. Mothers in the intervention arm breastfed for a longer duration than did the control subjects (median, 12.0 vs 6.5 weeks, respectively; P = .02) Mothers in the intervention arm were less likely to quit breastfeeding over the first 6 months after delivery (hazard ratio, 0.79; 95% confidence interval, 0.65-0.97). CONCLUSION A behavioral educational intervention increased breastfeeding duration among low-income, self-identified black and Latina mothers during the 6-month postpartum period.

Recruitment of Black and Latina Women to a Randomized Controlled Trial

Background. Minority women are often not adequately represented in randomized controlled trials, limiting the generalizability of research trial results. Methods. We implemented a recruitment strategy for a postpartum depression prevention trial that utilized patient feedback to identify and understand the recruitment barriers of Black and Latina postpartum women. Feedback on patients’ reasons for trial refusal informed adaptations to the recruitment process. We calculated weekly recruitment rates and analyzed qualitative and quantitative data from patient refusals. Results. Of the 668 women who were approached and completed the consent process, 540 enrolled in the trial and 128 declined participation. Over 52-weeks of recruitment, refusal rates decreased from 40% to 19%. A taxonomy of eight reasons for refusal derived from patient responses identified barriers to recruitment and generated targeted revisions to the recruitment message. Conclusions. A recruitment strategy designed to incorporate and respond to patient feedback improved recruitment of Black and Latina women to a clinical trial.

Severe Maternal Morbidity Among Hispanic Women in New York City: Investigation of Health Disparities

OBJECTIVE To investigate differences in severe maternal morbidity between Hispanic mothers and three major Hispanic subgroups compared with non-Hispanic white mothers and the extent to which differences in delivery hospitals may contribute to excess morbidity among Hispanic mothers. METHODS We conducted a population-based cross-sectional study using linked 2011-2013 New York City discharge and birth certificate data sets (n=353,773). Rates of severe maternal morbidity were calculated using a published algorithm based on diagnosis and procedure codes. Mixed-effects logistic regression with a random hospital-specific intercept was used to generate risk-standardized severe maternal morbidity rates for each hospital taking into consideration patient sociodemographic characteristics and comorbidities. Differences in the distribution of Hispanic and non-Hispanic white deliveries were assessed among these hospitals in relation to their risk-adjusted morbidity. Sensitivity analyses were conducted after excluding isolated blood transfusion from the morbidity composite. RESULTS Severe maternal morbidity occurred in 4,541 deliveries and was higher among Hispanic than non-Hispanic white women (2.7% compared with 1.5%, P<.001); this rate was 2.9% among those who were Puerto Rican, 2.7% among those who were foreign-born Dominican, and 3.3% among those who were foreign-born Mexican. After adjustment for patient characteristics, the risk remained elevated for Hispanic women (odds ratio [OR] 1.42, 95% confidence interval [CI] 1.22-1.66) and for all three subgroups compared with non-Hispanic white women (P<.001). Risk for Hispanic women was attenuated in sensitivity analyses (OR 1.17, 95% CI 1.02-1.33). Risk-standardized morbidity across hospitals varied sixfold. We estimate that Hispanic-non-Hispanic white differences in delivery location may contribute up to 37% of the ethnic disparity in severe maternal morbidity rates in New York City hospitals. CONCLUSION Hispanic compared with non-Hispanic white mothers are more likely to deliver at hospitals with higher risk-adjusted severe maternal morbidity rates and these differences in site of delivery may contribute to excess morbidity among Hispanic mothers. Our results suggest improving quality at the lowest performing hospitals could benefit both non-Hispanic white and Hispanic women and reduce ethnic disparities in severe maternal morbidity rates.

The role of obesity in the risk of gestational diabetes among immigrant and U.S.-born women in New York City

PURPOSE To examine if the role of obesity in the risk of gestational diabetes differs between immigrant and U.S.-born women. METHODS We used New York City-linked 2010-2014 birth certificate and hospital data. We created four racial/ethnic groups (non-Hispanic black, Hispanic, non-Hispanic white, and Asian) and three subgroups (Mexican, Indian, and Chinese). Gestational diabetes mellitus (GDM) was ascertained by the birth certificate checkbox and discharge ICD-9 codes. We calculated relative risks for immigrant status and body mass index with GDM using covariate-adjusted log-binomial regression. We calculated multivariable population attributable risk to estimate the proportion of GDM that could be eliminated if overweight/obesity were eliminated by immigrant status. RESULTS Immigrant women had higher risk of GDM than U.S.-born women, with adjusted relative risks ranging from 1.2 among non-Hispanic black women (95% confidence interval, 1.2-1.3) to 1.6 among Hispanic women (95% confidence interval, 1.4-1.8). Increasing body mass index was associated with GDM risk in all groups, but relative risks were weaker among immigrants (P for interaction <.05). The population attributable risk for overweight/obesity was lower in immigrant women than in U.S.-born women in all racial/ethnic groups. CONCLUSIONS The lower proportion of GDM attributable to overweight/obesity among immigrant women may point to early life and migration influences on risk of GDM.

Examining Trends in Obstetric Quality Measures for Monitoring Health Care Disparities

Background: Elective delivery (ED) before 39 weeks, low-risk cesarean delivery, and episiotomy are routinely reported obstetric quality measures and have been the focus of quality improvement initiatives over the past decade. Objective: To estimate trends and differences in obstetric quality measures by race/ethnicity. Research Design: We used 2008–2014 linked birth certificate–hospital discharge data from New York City to measure ED before 39 gestational weeks (ED <39), low-risk cesarean, and episiotomy by race/ethnicity. Measures were following the Joint Commission and National Quality Forum specifications. Average annual percent change (AAPC) was estimated using Poisson regression for each measure by race/ethnicity. Risk differences (RD) for non-Hispanic black women, Hispanic women, and Asian women compared with non-Hispanic white women were calculated. Results: ED<39 decreased among whites [AAPC=−2.7; 95% confidence interval (CI), −3.7 to −1.7), while it increased among blacks (AAPC=1.3; 95% CI, 0.1–2.6) and Hispanics (AAPC=2.4; 95% CI, 1.4–3.4). Low-risk cesarean decreased among whites (AAPC=−2.8; 95% CI, −4.6 to −1.0), and episiotomy decreased among all groups. In 2008, white women had higher risk of most measures, but by 2014 incidence of ED<39 was increased among Hispanics (RD=2/100 deliveries; 95% CI, 2–4) and low-risk cesarean was increased among blacks (RD=3/100; 95% CI, 0.5–6), compared with whites. Incidence of episiotomy was lower among blacks and Hispanics than whites, and higher among Asian women throughout the study period. Conclusions: Existing measures do not adequately assess health care disparities due to modest risk differences; nonetheless, continued monitoring of trends is warranted to detect possible emergent disparities.

Association of Race/Ethnicity With Very Preterm Neonatal Morbidities

Importance Severe morbidity in very preterm infants is associated with profound clinical implications on development and life-course health. However, studies of racial/ethnic disparities in severe neonatal morbidities are scant and suggest that these disparities are modest or null, which may be an underestimation resulting from the analytic approach used. Objective To estimate racial/ethnic differences in severe morbidities among very preterm infants. Design, Setting, and Participants This population-based retrospective cohort study was conducted in New York City, New York, using linked birth certificate, mortality data, and hospital discharge data from January 1, 2010, through December 31, 2014. Infants born before 24 weeks’ gestation, with congenital anomalies, and with missing data were excluded. Racial/ethnic disparities in very preterm birth morbidities were estimated through 2 approaches, conventional analysis and fetuses-at-risk analysis. The conventional analysis used log-binomial regression to estimate the relative risk of 4 severe neonatal morbidities for the racial/ethnic groups. For the fetuses-at-risk analysis, Cox proportional hazards regression with death as competing risk was used to estimate subhazard ratios associating race/ethnicity with each outcome. Estimates were adjusted for sociodemographic factors and maternal morbidities. Data were analyzed from September 5, 2017, to May 21, 2018. Main Outcomes and Measures Four morbidity outcomes were defined using International Classification of Diseases, Ninth Revision, diagnosis and procedure codes: necrotizing enterocolitis, intraventricular hemorrhage, bronchopulmonary dysplasia, and retinopathy of prematurity. Results In total, 582 297 infants were included in this study. Of these infants, 285 006 were female (48.9%) and 297 291 were male (51.0%). Using the conventional approach in the very preterm birth subcohort, black compared with white infants had an increased risk of only bronchopulmonary dysplasia (adjusted risk ratio [aRR], 1.34; 95% CI, 1.09-1.64) and a borderline increased risk of necrotizing enterocolitis (aRR, 1.39; 95% CI, 1.00-1.93). Hispanic infants had a borderline increased risk of necrotizing enterocolitis (aRR, 1.39; 95% CI, 0.98-1.96), and Asian infants had an increased risk of retinopathy of prematurity (aRR, 1.85; 95% CI, 1.15-2.97). In the fetuses-at-risk analysis, black infants had a 4.40 times higher rate of necrotizing enterocolitis (95% CI, 2.98-6.51), a 2.73 times higher rate of intraventricular hemorrhage (95% CI, 1.63-4.57), a 4.43 times higher rate of bronchopulmonary dysplasia (95% CI, 2.88-6.81), and a 2.98 times higher rate of retinopathy of prematurity (95% CI, 2.01-4.40). Hispanic infants had an approximately 2 times higher rate for all outcomes, and Asian infants had increased risk only for retinopathy of prematurity (adjusted hazard ratio, 2.43; 95% CI, 1.43-4.11). Conclusions and Relevance In this study, racial/ethnic disparities in neonatal morbidities among very preterm infants appear to be sizable, but may have been underestimated in previous studies, and may have implications for the future. Understanding these racial/ethnic disparities is important, as they may contribute to inequalities in health and development later in the child’s life.

Delivery and Payment Redesign to Reduce Disparities in High Risk Postpartum Care

Purpose This paper describes the implementation of an innovative program that aims to improve postpartum care through a set of coordinated delivery and payment system changes designed to use postpartum care as an opportunity to impact the current and future health of vulnerable women and reduce disparities in health outcomes among minority women. Description A large health care system, a Medicaid managed care organization, and a multidisciplinary team of experts in obstetrics, health economics, and health disparities designed an intervention to improve postpartum care for women identified as high-risk. The program includes a social work/care management component and a payment system redesign with a cost-sharing arrangement between the health system and the Medicaid managed care plan to cover the cost of staff, clinician education, performance feedback, and clinic/clinician financial incentives. The goal is to enroll 510 high-risk postpartum mothers. Assessment The primary outcome of interest is a timely postpartum visit in accordance with NCQA healthcare effectiveness data and information set guidelines. Secondary outcomes include care process measures for women with specific high-risk conditions, emergency room visits, postpartum readmissions, depression screens, and health care costs. Conclusion Our evidence-based program focuses on an important area of maternal health, targets racial/ethnic disparities in postpartum care, utilizes an innovative payment reform strategy, and brings together insurers, researchers, clinicians, and policy experts to work together to foster health and wellness for postpartum women and reduce disparities.

Stigma and Postpartum Depression Treatment Acceptability Among Black and White Women in the First Six-Months Postpartum

Objective To measure stigma associated with four types of postpartum depression therapies and to estimate the association between stigma and the acceptance of these therapies for black and white postpartum mothers. Methods Using data from two postpartum depression randomized trials, this study included 481 black and white women who gave birth in a large urban hospital and answered a series of questions at 6-months postpartum. Survey items included socio demographic and clinical factors, attitudes about postpartum depression therapies and stigma. The associations between race, stigma, and treatment acceptability were examined using bivariate and multivariate analyses. Results Black postpartum mothers were less likely than whites to accept prescription medication (64 vs. 81%, p = 0.0001) and mental health counseling (87 vs. 93%, p = 0.001) and more likely to accept spiritual counseling (70 vs. 52%, p = 0.0002). Women who endorsed stigma about receipt of postpartum depression therapies versus those who did not were less likely to accept prescription medication, mental health and spiritual counseling for postpartum depression. Overall black mothers were less likely to report stigma associated with postpartum depression therapies. In adjusted models, black women versus white women remained less likely to accept prescription medication for postpartum depression (OR = 0.42, 95% CI 0.24–0.72) and stigma did not explain this difference. Conclusions Although treatment stigma is associated with lower postpartum depression treatment acceptance, stigma does not explain the lower levels of postpartum depression treatment acceptance among black women. More research is needed to understand treatment barriers for postpartum depression, especially among black women.