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SMFM Special Report| Volume 218, ISSUE 2, PB9-B17, February 2018

SMFM Special Report: Putting the “M” back in MFM: Reducing racial and ethnic disparities in maternal morbidity and mortality: A call to action

Published:November 25, 2017DOI:https://doi.org/10.1016/j.ajog.2017.11.591
      Racial and ethnic disparities in maternal morbidity and mortality rates are an important public health problem in the United States. Because racial and ethnic minorities are expected to comprise more than one-half of the US population by 2050, this issue needs to be addressed urgently. Research suggests that the drivers of health disparities occur at 3 levels: patient, provider, and system. Although we have recognized this issue and identified elements that contribute to it, knowledge must be converted into action to address it. In addition, despite available funding and databases, research directed towards understanding and reducing these disparities is lacking. This document summarizes findings of a workshop convened at the 2016 Society for Maternal-Fetal Medicine’s 36th Annual Pregnancy meeting in Atlanta, GA, to review and make recommendations about immediate actions in clinical care and research that will serve to reduce racial and ethnic disparities in maternal morbidity and mortality rates in the United States.

      Key words

      Racial and ethnic disparities in maternal morbidity and mortality rates remain unacceptably large in the United States. The fact that black women in the United States are 1–3 times more likely than white women to die from pregnancy-related complications and are more likely to have a preventable death serves to illustrate the need for the reduction of these disparities.
      • Tucker M.J.
      • Berg C.J.
      • Callaghan W.M.
      • Hsia J.
      The black-white disparity in pregnancy-related mortality from 5 conditions: differences in prevalence and case-fatality rates.
      • Bryant A.S.
      • Worjoloh A.
      • Caughey A.B.
      • Washington A.E.
      Racial/ethnic disparities in obstetric outcomes and care: prevalence and determinants.
      The drivers of healthcare disparities exist at 3 main levels, as described by Kilbourne et al
      • Kilbourne A.
      • Switzer G.
      • Hyman K.
      • et al.
      Advancing health disparities research within the health care system: a conceptual framework.
      : patient, provider, and system. Patient-level factors include the perceptions of the quality of care received, the quality of the relationship with the healthcare provider, and perceptions of health and illness from a sociocultural context. Patients’ perceptions related to their interpretations of symptoms of illness, the services they receive, and their sense of control over a proposed treatment regimen all represent personal and nonstructural barriers to healthcare.
      • Beal A.C.
      • Abrams M.
      • Saul J.
      Healthcare workforce diversity: developing physician leaders. Testimony before the Sullivan Commission on Diversity in the Healthcare Workforce.
      • Davis S.D.
      • Ford M.E.
      A conceptual model of barriers to mental health services among African Americans.
      • Hines-Martin V.
      • Malone M.
      • Kim S.
      • Brown-Piper A.
      Barriers to mental health care access in an African American population.
      • Macran S.
      • Ross H.
      • Hardy G.E.
      • Shapiro D.A.
      The importance of considering clients' perspectives in psychotherapy research.
      Provider factors, which include the knowledge and attitudes of physicians, nurses, social workers, and other healthcare providers, may contribute to disparities in healthcare. Provider bias is also an important factor; unconscious (implicit) racial bias among physicians regarding treatment decisions has been shown to exist, even when physicians do not portray conscious (explicit) bias.
      • Green A.R.
      • Carney D.R.
      • Pallin D.J.
      • Ngo L.H.
      • Raymond K.L.
      • Iezzoni L.I.
      • Banaji M.R.
      Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients.
      There is a growing emphasis on the improvement of cultural competency among providers, that is, the establishment of effective interpersonal and working relationships with patients by recognizing the social and cultural influences that are important to them.
      • Cooper L.
      • Roter D.
      Patient-provider communication: the effect of race and ethnicity on process and outcomes of healthcare.
      • Betancourt J.R.
      • Green A.R.
      • Carrillo J.E.
      • Ananeh-Firempong O.
      Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care.
      • Beach M.
      • Price E.
      • Gary T.
      • et al.
      Cultural competency: a systematic review of health care provider educational interventions.
      System-level factors that contribute to disparities include healthcare systems and services, financing, access to and use of healthcare, and the quality of care that is delivered. Several studies have demonstrated the presence of structural barriers to care that may reduce the likelihood of a patient making and keeping a healthcare appointment. These factors include lack of transportation, lack of or inadequate health insurance, scarcity of providers, and inconvenient health services locations.
      • Copeland V.
      African Americans: disparities in health care access and utilization.
      • Andersen R.
      Revisiting the behavioral model and access to medical care: does it matter?.
      • Beal A.
      Policies to reduce racial and ethnic disparities in child health and health care.
      • Frist W.
      Overcoming disparities in U.S. health care.
      US Department of Health and Human Services
      Mental health: a report of the Surgeon General.
      US Department of Health and Human Services, Health Resources and Services Administration
      Cultural competence works.
      US Department of Health and Human Services
      Mental health: culture, race, and ethnicity-a supplement to mental health: a report of the Surgeon General.
      • Kennedy E.
      The role of the federal government in eliminating health disparities.
      • Owens P.
      • Hoagwood K.
      • Horwitz S.
      Barriers to children's mental health services.
      However, even after acquiring access to healthcare services, women of racial and ethnic minority groups continue to experience poor quality and differential care.
      • Ayanian J.
      • Landon B.
      • Newhouse J.
      • et al.
      Racial and ethnic disparities among enrollees in Medicare Advantage plans.
      Racial and ethnic disparities in healthcare represent an urgent crucial issue, with particular urgency a critical issue for providers to recognize and address. Racial and ethnic minorities are expected to comprise more than one-half of the US population by 2050.
      • Colby S.
      • Ortman J.
      Projections of the size and composition of the US population: 2014 to 2060: current population reports, P25–1143.
      The problem is compounded by the significant lack of research that has been directed toward the reduction of these disparities, despite the fact that relevant databases exist and funding is available. Consequently, a workshop was convened at the Society for Maternal-Fetal Medicine’s (SMFM) 36th Annual Pregnancy Meeting in Atlanta, GA, on February 1, 2016, to review existing data on clinical care and racial and ethnic disparities and to identify research gaps in this area. This document summarizes the findings that were presented, highlights the gaps that exist in clinical care and research, and makes specific recommendations to reduce the disparities in maternal morbidity and mortality rates.

      Clinical care

      There are several areas in which clinical care providers can focus efforts to reduce disparities. For example, hypertensive disorders of pregnancy disproportionately affect minority women, who also have a higher risk of adverse outcomes, which include severe maternal morbidity compared with nonminority women.
      • Miranda M.
      • Swamy G.
      • Edwards S.
      • et al.
      Disparities in maternal hypertension and pregnancy outcomes: evidence from North Carolina, 1994-2003.
      Furthermore, the in-hospital mortality rate for black women is higher than that for white women (odds ratio, 2.85; 95% confidence interval, 1.38–5.53) with preeclampsia.
      • Shahul S.
      • Tung A.
      • Minhaj M.
      • et al.
      Racial disparities in comorbidities, complications, and maternal and fetal outcomes in women with preeclampsia/eclampsia.
      If we consider the scenario of 2 women who begin pregnancy with chronic hypertension, 1 white and the other black, a standard and equal approach to both women may not be ideal and may contribute to a disparity in outcome. For the described patients, it is important to note that, for any given duration of hypertension, black women are more likely to have end-organ manifestations of hypertensive disease.
      • Go A.S.
      • Mozaffarian D.
      • Roger V.L.
      • et al.
      Heart disease and stroke statistics: 2014 update: a report from the American Heart Association.
      • Howell E.A.
      • Egorova N.
      • Balbierz A.
      • et al.
      Black-white differences in severe maternal morbidity and site of care.
      Therefore, a clinical protocol that does not include an algorithm for the identification of women who are at high risk based on racial or ethnic background (such as minority women with chronic hypertension, diabetes mellitus, and morbid obesity) may hinder our ability to treat them appropriately and may contribute to a disparity in outcomes.
      Additionally, because black and white women differ in their responses to antihypertensive therapy, these differences should be recognized when treatment plans are being developed. When postpartum treatment is being planned for black women with chronic hypertension, calcium channel blockers and thiazide diuretics have demonstrated better effectiveness in this population and are the antihypertensive agents of choice for long-term treatment.
      • Chobanian A.V.
      • Bakris G.L.
      • Black H.R.
      • et al.
      The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report.
      Antihypertensive treatment in these women should also include a Dietary Approaches to Stop Hypertension diet, which is as effective as monotherapy in blood pressure reduction and has been shown to improve pregnancy outcomes in certain subsets of the population.
      • James P.A.
      • Oparil S.
      • Carter B.L.
      • et al.
      2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8).
      • Go A.S.
      • Bauman M.A.
      • Coleman King S.A.
      An effective approach to high blood pressure control: a science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention.
      • Asemi Z.
      • Samimi M.
      • Tabassi Z.
      • Esmaillzadeh A.
      The effect of DASH diet on pregnancy outcomes in gestational diabetes: a randomized controlled trial.
      It is not possible to discuss the disparities in any condition without discussing the systems factors that may contribute to them. An important system-level factor that impacts clinical care is the availability of transportation to in-person visits. Cab vouchers or other transit programs may help with this barrier. The frequency of scheduled in-person visits poses another challenge; new innovations in remote monitoring programs may assist in improved patient-centered care. For minority women who do not speak English, failures in adequate communication can also contribute to disparities. Increasing the availability of interpreter services, both in person and on the phone, could support improvements in this area.
      • Flores G.
      The impact of medical interpreter services on the quality of health care: a systematic review.
      • Jacobs E.A.
      • Shepard D.S.
      • Suaya J.A.
      • Stone E.L.
      Overcoming language barriers in health care: costs and benefits of interpreter services.
      • Jacobs E.A.
      • Lauderdale D.S.
      • Meltzer D.
      • Shorey J.M.
      • Levinson W.
      • Thisted R.A.
      Impact of interpreter services on delivery of health care to limited-English-proficient patients.
      Finally, to improve the overall care of vulnerable populations, access to a full range of multidisciplinary services is necessary, which includes social work, behavioral health services, care coordination, community health workers, and nutrition services.
      In discussing system-level factors, it is also important to expand our scope and understand the effect that the current health system in the United States has on disparities. Under the current system, populations that have commercial insurances are favored to receive care at better quality hospitals with superior access to private subspecialty care compared with populations that primarily use Medicaid.
      • Zuvekas S.
      • Taliaferro G.
      Pathways to access: health insurance, the health care delivery system, and racial/ethnic disparities, 1996-1999.
      Because black and Hispanic populations are much less likely to be insured privately than white populations, a significant racial disparity exists.
      • Zuvekas S.
      • Taliaferro G.
      Pathways to access: health insurance, the health care delivery system, and racial/ethnic disparities, 1996-1999.
      • Ammons L.
      Demographic profile of health-care coverage in America in 1993.
      Furthermore, those women who are undocumented experience even greater access issues, and how providers can access federally funded clinics and services for this vulnerable population deserves study. The increasingly diverse population of the United States may be better served by a health system with a more uniform approach to healthcare payments. To address racial and ethnic disparities on a healthcare system level, it is important to recognize and address these disparities with respect to health insurances, which ultimately determine the access to quality care.
      A summary of the recommendations to reduce disparities in maternal morbidity and mortality rates are presented in Table 1.
      Table 1Summary of recommendations to improve clinical care
      RecommendationsRationaleDescription
      For providers
       Use available preventive therapies for high-risk women.Prevention strategies in high-risk women can lead to an improvement in healthcare costs and care outcomes.
      • Keating C.
      • Harrison C.
      • Lombard C.
      • et al.
      Healthcare costs associated with gestational diabetes mellitus during pregnancy and potential cost-effectiveness of prevention in high-risk women.
      Prescribe low-dose aspirin to prevent preeclampsia according to US Preventive Services Task Force guidelines.
       Assess baseline end-organ damage among high-risk women.Black women are more likely to have end-organ damage for any given duration of hypertension.
      • Go A.S.
      • Mozaffarian D.
      • Roger V.L.
      • et al.
      Heart disease and stroke statistics: 2014 update: a report from the American Heart Association.
      Consider an algorithm for high-risk women who may benefit from a maternal echocardiogram, renal function evaluation, and sleep apnea screening either before or early in pregnancy.
       Follow existing clinical guidelines.Specific societies may have recommendations for the management of medical conditions; only 10–40% of women with hypertension or diabetes mellitus will see a primary care provider within 1 year after delivery.
      • Bennett W.L.
      • Chang H.Y.
      • Levine D.M.
      • et al.
      Utilization of primary and obstetric care after medically complicated pregnancies: an analysis of medical claims data.
      Follow existing evidence-based guidelines (American Heart Association guidelines for treatment of hypertension; National Institute for Health and Care Excellence guideline key recommendations for a 6- to 8-week postpartum consultation).
      • Go A.S.
      • Bauman M.A.
      • Coleman King S.A.
      An effective approach to high blood pressure control: a science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention.
      National Collaborating Centre for Primary Care (UK)
      NICE Clinical Guidelines. Postnatal care: routine postnatal care of women and their babies.
      For healthcare systems
       Provide supportive services that facilitate access to care.Improved access to care is associated with significant increases in usage, preventive care, healthcare quality, and self-reported health, in addition to reductions in emergency department use.
      • Sommers B.D.
      • Blendon R.J.
      • Orav E.J.
      • Epstein A.M.
      Changes in utilization and health among low-income adults after Medicaid expansion or expanded private insurance.
      Incorporate standardized, culturally appropriate patient education materials that illustrate the link between pregnancy complications and future health.
      Provide transportation vouchers and translation services.
      Provide remote visits and home visits when possible. Consider using community-based initiatives to enhance prenatal and postnatal care.
      For hospital systems
       Improve the quality of the care provided.Black women are more likely to deliver at hospitals that serve a predominately black population and have high rates of morbidity.
      • Howell E.A.
      • Egorova N.
      • Balbierz A.
      • et al.
      Black-white differences in severe maternal morbidity and site of care.
      Incorporate recommended care bundles that are related specifically to hypertension, venous thromboembolism prevention, and postpartum hemorrhage.
      Partner with lower resource hospitals to help improve healthcare quality.
       Implement maternal morbidity and mortality reviews.Mortality reviews can help identify areas of substandard

      care that need improvement.
      • De Brouwere V.
      • Zinnen V.
      • Delvaux T.
      How to conduct maternal death reviews (MDR). Guidelines and Tools for Health Professionals.
      Undertake a systematic, multidisciplinary review of all cases of death and severe morbidity.
      • Callaghan W.M.
      • Grobman W.A.
      • Kilpatrick S.J.
      • Main E.K.
      • D’Alton M.
      Facility-based identification of women with severe maternal morbidity: it is time to start.
      Establish a mechanism to disseminate knowledge gained from those reviews.
      Jain. SMFM special report. Am J Obstet Gynecol 2018.

      Contraception care as an illustrative example

      Contraception care serves as an important example of the disparities that exist in women’s healthcare. Nearly one-half of all pregnancies that occur in the United States are unplanned, and minority and low-income women are 2–3 times more likely to experience an unintended pregnancy compared with white or higher income women.
      • Finer L.B.
      • Zolna M.R.
      Declines in unintended pregnancy in the United States, 2008-2011.
      • Finer L.B.
      • Henshaw S.K.
      Disparities in unintended pregnancy in the United States, 1994 and 2001.
      • Sonfeld A.
      • Kost K.
      • Gold R.B.
      • Finer L.B.
      The public costs of births resulting from unintended pregnancies: national and state-level estimates.
      • Finer L.
      • Zolna M.
      Shifts in intended and unintended pregnancies in the United States, 2001-2008.
      All other adverse family planning outcomes, including abortions, unintended births, and teen pregnancies, occur more commonly among minority women.
      • Dehlendorf C.
      • Rodriguez M.I.
      • Levy K.
      • Borrero S.
      • Steinauer J.
      Disparities in family planning.
      • Barrett G.
      • Smith S.C.
      • Wellings K.
      Conceptualization, development, and evaluation of a measure of unplanned pregnancy.
      Minority women are less likely to use contraception overall or a consistent method of contraception. They also have higher rates of contraceptive failure than white women.
      • Dehlendorf C.
      • Rodriguez M.I.
      • Levy K.
      • Borrero S.
      • Steinauer J.
      Disparities in family planning.
      • Mosher W.D.
      • Martinez G.M.
      • Chandra A.
      • Abma J.C.
      • Wilson S.J.
      Use of contraception and use of family planning services in the United States: 1982-2002.
      Even when using the same method of contraception, minority women experience higher rates of method failure and discontinuation.
      • Dehlendorf C.
      • Rodriguez M.I.
      • Levy K.
      • Borrero S.
      • Steinauer J.
      Disparities in family planning.
      • Ranjit N.
      • Bankole A.
      • Darroch J.E.
      • Singh S.
      Contraceptive failure in the first two years of use: differences across socioeconomic subgroups.
      • Trussell J.
      • Vaughan B.
      Contraceptive failure, method-related discontinuation and resumption of use: results from the 1995 National Survey of Family Growth.
      • Fu H.
      • Darroch J.
      • Haas T.
      • et al.
      Contraceptive failure rates: new estimates from the 1995 National Survey of Family Growth.
      • Vaughan B.
      • Trussell J.
      • Kost K.
      • et al.
      Discontinuation and resumption of contraceptive use: Results from the 2002 National Survey of Family Growth.
      Unfortunately, efforts aimed at improving unintended pregnancy rates to date disproportionately have benefited higher income and non-Hispanic white women.

      Guttmacher Institute. Unintended pregnancy in the United States. Available at: http://www.guttmacher.org/pubs/FB-Unintended-Pregnancy-US.html. 2016. Accessed April 13, 2016.

      • Jones J.
      • Mosher W.
      • Daniels K.
      Current contraceptive use in the United States, 2006–2010, and changes in patterns of use since 1995.
      Several areas were identified at the SMFM workshop in which practical changes could be implemented to have a positive impact. From a patient care perspective, provider encouragement of optimal birth spacing and the prevention of unintended pregnancies are crucial steps in decreasing overall maternal morbidity and mortality rates, because women with short interpregnancy intervals are more likely to experience adverse maternal and infant outcomes.
      • Cofer F.G.
      • Fridman M.
      • Lawton E.
      • Korst L.M.
      • Nicholas L.
      • Gregory K.D.
      Interpregnancy interval and childbirth outcomes in California, 2007–2009.
      With regards to contraception and access among minority women, we are beginning to see a reduction in barriers, particularly those pertaining to cost and insurance coverage. One of the highlights of the Patient Protection and Affordable Care Act was the contraceptive coverage mandate that all Food and Drug Administration–approved methods be covered (for women who have commercial insurance) without additional cost sharing.

      Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 et seq. (2010).

      The implementation of this mandate resulted in a substantial increase in the number of women who used contraceptive methods that require a prescription. However, disparities for women without commercial insurance, which includes those with insurance coverage that ends shortly after pregnancy, also need to be addressed. One way to address these disparities is to find innovative ways to use the Affordable Care Act benefit to obtain contraceptive methods for women during pregnancy so that they are readily available during the postpartum period. Another is to ensure that long-acting reversible contraceptive (LARC) options are covered by Medicaid, because these approaches become prohibitively expensive if not covered. The total bill for a patient to initiate LARC may exceed $1000, and out-of-pocket costs negatively influence the decision to obtain a LARC method.
      • Eisenberg D.
      • McNicholas C.
      • Peipert J.F.
      Cost as a barrier to long-acting reversible contraceptive (LARC) use in adolescents.
      • Trussel J.
      Update on and correction to the cost effectiveness of contraceptives in the United States.
      • Gariepy A.M.
      • Simon E.J.
      • Patel D.A.
      • Creinin M.D.
      • Schwarz E.B.
      The impact of out-of-pocket expense on IUD utilization among women with private insurance.
      • Homco J.B.
      • Peipert J.F.
      • Secura G.M.
      • Lewis V.A.
      • Allsworth J.E.
      Reasons for ineffective pre-pregnancy contraception use in patients seeking abortion services.
      State-based efforts to improve Medicaid coverage of LARC at the time of delivery are promising developments that must continue in order to extend these benefits to all states.

      Advocacy

      As we work to improve racial and ethnic disparities in maternal healthcare, we must recognize that improvements in the quality or use of medical systems are not sufficient to achieve full equity for minorities.
      • McGinnis J.M.
      • Williams-Russo P.
      • Knickman J.R.
      The case for more active policy attention to health promotion.
      US Department of Health & Human Services
      Ten leading causes of death in the United States.
      Relevant socioeconomic factors also play pivotal roles in healthcare disparities, with barriers for patients as simple as a lack of transportation to clinic appointments. It is therefore important that advocacy extend outside of the sphere of medicine and include a focus on social justice. Providers can advocate on behalf of their patients for states to provide more access to housing, food, and transportation in addition to healthcare. Other priorities include the provision of contraceptive coverage for high-risk populations, a redesign of the standard 6-week postpartum visit, incorporation of the concept of maternal health disparities in training programs and in Maintenance of Certification, and development of new resource materials to educate providers about maternal health disparities.

      Research gaps

      The participants of the workshop discussed the current state of research into disparities in maternal health, identified research gaps, and discussed opportunities for funding such research. The general framework put forth for research into disparities in health outcomes and care involves identification and quantification of the problem, understanding the underlying causes, and testing interventions.
      McGinnis and Foege
      • McGinnis J.M.
      • Foege W.H.
      Actual causes of death in the United States.
      have suggested that population health status, as measured by premature death, is defined by disparities in biology, social circumstances, environmental exposures, behavioral patterns, and medical care. Research is needed in each of these domains to determine their specific impact on disparities in maternal health. In their construct, these domains contribute to disparities differently; some estimates suggest that biology and genetics account for approximately 30% of the differences in overall premature death among different racial and ethnic groups. Behavioral patterns account for 40% of the difference; social circumstances account for 15%; and environmental exposures account for 5%. Shortfalls in medical care are estimated to account for 10% of these differences.
      • McGinnis J.M.
      • Williams-Russo P.
      • Knickman J.R.
      The case for more active policy attention to health promotion.
      US Department of Health & Human Services
      Ten leading causes of death in the United States.
      • McGinnis J.M.
      • Foege W.H.
      Actual causes of death in the United States.
      It must be noted, however, that because of the lack of data in this area, a wide range has been reported for any given contribution. It is not known whether the relative contributions of genetics, behavior, social and environmental exposures, and access to medical care specific to disparities in maternal health outcomes are similar. The quality of the evidence regarding the contributions of these domains to health disparities is generally level B or C, with relatively little level A evidence. This area represents an enormous opportunity for further investigation.
      A significant challenge to conducting maternal health disparity research is that disparities are measured, presented, and discussed inconsistently. Disparity may be measured as a “crude difference” (a mathematic difference in means or proportions) and an “adjusted difference” (a residual difference in outcomes after adjustment for potential confounders). The latter is most commonly used, but it may fail to account for the clinical care factors, healthcare system factors, and structural factors that influence how race or ethnicity contribute to health. A third way of measuring disparity is as a “difference not explained by differences in health status,” which is likely the most accurate way to assess disparities but the least used because differences in health status are more difficult to measure.
      • Le Cook B.
      • McGuire T.G.
      • Zuvekas S.H.
      Measuring trends in racial/ethnic health care disparities.
      The most commonly performed studies on disparities are observational, either from administrative data, institutional data, or secondary analyses of prospective data that were collected for a different purpose.
      • Thomas S.B.
      • Quinn S.C.
      • Butler J.
      • Fruer C.S.
      • Garza M.A.
      Toward a fourth generation of disparities research to achieve health equity.
      Although observational studies have limitations, which include the possibility of selection bias and confounding by unmeasured factors, they do provide important insights into the problem of racial and ethnic disparities. Intervention and implementation studies are needed to evaluate potential treatments, policies, or actions that can reduce disparities.
      • Thomas S.B.
      • Quinn S.C.
      • Butler J.
      • Fruer C.S.
      • Garza M.A.
      Toward a fourth generation of disparities research to achieve health equity.
      There are currently few intervention and implementation studies that relate to disparities in maternal morbidity and mortality rates. Data about the biology that may underlie racial and ethnic disparities are lacking. Existing data focus on pharmacogenetics (medication effects in different races or ethnicities) or minority-specific diseases (eg, sickle cell disease) that overwhelmingly affect 1 racial or ethnic group. Finally, insufficient information is available about the structural drivers of inequity and the obstacles to equitable healthcare. There is a great need for further research in each of these areas that pertain to disparities in maternal healthcare, just as there is a need for research into disparities in health outcomes, with a focus on the quality of care that is provided for minority women.

      Research gap priorities

      The conference identified several important research gaps that should be priorities for advocacy and funding. Five specific research gap priorities were identified: (1) accurate identification of race/ethnicity, (2) variation in hospital quality by race/ethnicity served, (3) disparity in postpartum hemorrhage, (4) disparities in hypertensive disorders of pregnancy, and (5) differences in patient and provider-related factors. Proposed research plans to address these gaps are listed in Table 2.
      Table 2Examples of research gaps in maternal health disparities research
      Research gapJustificationProposed research
      Identification of race/ethnicityThere is a need for standardized reporting.Collect data related to race/ethnicity in a thorough and consistent manner, including country of origin and ethnicity.
      Recent refinement of Agency for Healthcare Research and Quality definitions led to seven distinct race/ethnicities, but the selections remain limited and puts individuals of genetically and geographically distinct ethnicities in the same categories.
      Institute of Medicine (US) Subcommittee on Standardized Collection of Race/Ethnicity Data for Healthcare Quality Improvement
      Explore the association between additional levels of ethnicity (eg, sub-Saharan African vs African American) and outcomes.
      Granular data about race/ethnicity is important to identify differences in outcomes and target interventions.Use patterns and associations that are identified to provide opportunities for specific interventions.
      Variation in hospital qualityMany factors contribute to disparity in low-resource hospitals: morbidities of patient, quality of care provided, characteristics of hospital, hospital volumes.Use available hospital quality metrics to evaluate disparities while accounting for different populations served.
      Many hospitals have standardized protocols for obstetrics, but it is unclear whether these protocols reduce disparities in maternal morbidity and death.Explore epidemiologic analysis to examine variations in hospital markers, including delivery volume and risk stratification that may predict outcomes.
      It is unclear whether there are disparities in the recognition of maternal morbidity and death that vary by hospital.Evaluate the effects of implementation of standardized protocols in relation to race/ethnicity of patients.
      Postpartum hemorrhageDisparities exist in outcomes related to obstetric hemorrhage, with disparity in the rates of hemorrhage and receipt of blood transfusions, despite similar rates of risk factors for hemorrhage.
      • Creanga A.A.
      • Bateman B.T.
      • Kuklina E.V.
      • Callaghan W.M.
      Racial and ethnic disparities in severe maternal morbidity: a multistate analysis, 2008-2010.
      • Grobman W.A.
      • Bailit J.L.
      • Rice M.M.
      • et al.
      Frequency of and factors associated with severe maternal morbidity.
      • Bryant A.
      • Mhyre J.M.
      • Leffert L.R.
      • Hoban R.A.
      • Yakoob M.Y.
      • Bateman B.T.
      The association of maternal race and ethnicity and the risk of postpartum hemorrhage.
      Identify the pathophysiologic condition behind increased postpartum hemorrhage and need for transfusions, including possible association with increased risk factors (ie, uterine myomas) or presence of genetic predisposition.
      It is unclear whether these disparities are related to patient, provider, or healthcare system differences.Evaluate nonphysiologic factors related to increases in hemorrhage and need for transfusion.
      Evaluate efficacy of postpartum hemorrhage protocols by race/ethnicity.
      Hypertensive disorders of pregnancyRacial/ethnic minorities have higher rates of hypertension during pregnancy and are more likely to present with higher blood pressures.
      • Hill L.
      • Hilliard D.
      • York T.
      • et al.
      Fetal ERAP2 variation is associated with preeclampsia in African Americans in a case-control study.
      Explore associations between responses to different classes of antihypertensive medications among different racial/ethnic groups during pregnancy and the postpartum period.
      In obstetric populations, certain classes of medications are more effective in minorities; despite this, pregnant women are often switched to less efficacious medications.Consider a clinical trial to assess antepartum and postpartum antihypertensive regimen efficacy by race/ethnicity.
      Patient and provider factorsSignificant evidence exists to suggest that providers may be impacted by underlying inherent bias.Assess provider awareness of disparities in health outcomes and determine effective modalities to provide education to providers.
      Providers may present different interpretations of medical information based on cultural or language differences.Explore effective methods to increase provider self-awareness of the biases they bring to patient encounter.
      Patients may have racial/ethnic group–based mistrust of providers based on historic factors (eg, the Tuskegee syphilis experiment and history of forced sterilization of minorities).Develop new strategies and modalities for patient and community education regarding healthcare.
      Evaluate the impact of collaborative care models, such as the pregnancy home, on outcomes.
      Jain. SMFM special report. Am J Obstet Gynecol 2018.
      In addition to disparities in health outcomes and healthcare and the research gaps discussed earlier, racial and ethnic minorities are underrepresented in research, both as subjects and investigators. For example, the ethnic composition of research participants in intervention trials for diabetes mellitus consists of 85% non-Hispanic white individuals and only 11% black, 4% Hispanic, and 0% Asian-American individuals.
      • Le Cook B.
      • McGuire T.G.
      • Zuvekas S.H.
      Measuring trends in racial/ethnic health care disparities.
      Moreover, evidence suggests that the discrepancy in the rates of enrollment in research studies is not due to a lack of willingness to participate among patients of racial and ethnic minority groups but rather to a lack of access to enrollment in health research studies.
      • Wendler D.
      • Kington R.
      • Madans J.
      • et al.
      Are racial and ethnic minorities less willing to participate in health research?.
      It follows that further investigation is needed to identify ways to improve access to health research among minorities.
      Minority groups are also underrepresented as research investigators. For example, there is significant racial/ethnic disparity in investigators who are funded by the National Institutes of Health (NIH). Black individuals make up 12.6% of the US population but only 1.1% of NIH-funded investigators.

      United States Census Bureau. 2010 Census. Available at: http://www.census.gov/2010census/data/. Accessed April 13, 2016.

      A recent study demonstrated that the proportion of funded NIH investigator–initiated grant applications is 13% lower for black applicants and 4% lower for Asian applicants than for white applicants.
      • Ginther D.
      • Schaffer W.
      • Schnell J.
      Race, ethnicity, and NIH research awards.
      This disparity in minority representation among investigators must be addressed from many angles, which include improved access to training, recruitment, and funding for minority investigators.

      Research support

      Federal agencies such as the NIH, Centers for Disease Control and Prevention, Health Resources and Service Administration, and Agency for Healthcare Research and Quality continue to support research and translational work related to health disparities. The NIH has 18 institutes and centers that fund research on topics related to health disparity. After the applications are peer-reviewed by scientists in various review groups, the NIH Institutes and Centers evaluate proposals for programmatic relevance. After a second level of review by the respective National Advisory Council, funding is granted based on scientific merit, programmatic relevance, and the availability of funds. To achieve high scores in the peer review sessions, researchers-at-large who propose applications on topics related to health disparities are encouraged to contact specific program officials within each institute or center for explicit guidelines in developing strong research proposals.
      Although most funded applications are investigator-initiated, the NIH and Centers often solicit applications through funding opportunity announcements via Request for Applications, which have funds allocated, or through Program Announcements and Program Announcements with Referral, which do not usually have specifically allocated funds. The NIH Grants and Funding website (https://www.nih.gov/grants-funding) can be searched for active funding opportunity announcements.

      US Department of Health & Human Services. National Institutes of Health. NIH Funding. Available at: https://grants.nih.gov/grants/guide/index.html. Accessed April 14, 2016.

      One currently active funding opportunity announcement seeks a proposal for a research conference grant to conduct health disparity–related meetings, workshops, or symposia to bring together academic institutions and community organizations to identify opportunities for addressing health disparities through community-based participatory research. Interested researchers can subscribe to the weekly NIH Guide, which provides information regarding new and active funding opportunities.

      US Department of Health & Human Services. National Institutes of Health. NIH Guide for grants and contracts advanced search. Available at: https://grants.nih.gov/searchGuide/Search_Guide_Results.cfm?RFAsToo=0. Accessed April 14, 2016.

      It is also important to note that the NIH offers loan repayment funding for researchers who work in the area of health disparities. The NIH RePORT (https://report.nih.gov/) website can also be searched for recently funded projects on any topic of interest.

      US Department of Health & Human Services. National Institutes of Health. Research Portfolio Online Reporting Tools (RePORTER). Query Form. Available at: https://projectreporter.nih.gov/reporter.cfm. Accessed April 14, 2016.

      The Patient-Centered Outcomes Research Institute (PCORI) is an independent, nonprofit, nongovernmental organization that aims to produce evidence-based information regarding health outcomes.

      Patient-Centered Outcomes Research Institute (PCORI). Available at: http://www.pcori.org. Accessed February 2, 2017.

      PCORI provides funding for comparative clinical effectiveness research and supports work that improves the methods that are used to conduct such studies. More information can be found at their website: http://www.pcori.org.
      For researchers who are interested in conducting health disparity research, several data sets are available for public access. The Eunice Kennedy Shriver National Institute for Child Health and Human Development (NICHD) Data and Specimen Hub (DASH) is a centralized resource to store and access deidentified data from NICHD-funded studies. It encourages NICHD-funded intramural and extramural investigators to share research data. Data from 17 completed NICHD-funded studies are currently available, with several more being added (Table 3).
      Table 3Data from completed National Institute for Child Health and Human Development–funded studies for potential disparities research
      Data SourceDescriptionWebsite
      Eunice Kennedy Shriver National Institute for Child Health and Human Development (NICHD) Data and Specimen Hub (DASH)Centralized resource to store and access de-identified data from NICHD-funded studies.https://dash.nichd.nih.gov
      All Maternal-Fetal Medicine Unit Network (MFMU) studies with publicly available data are accessible through DASH.
      National Children’s Study (NCS) Pilot DataThe Vanguard study enrolled 5000 children from 40 locations across the country; data from this study are available separately from the NICHD DASH.https://www.nichd.nih.gov/research/supported/NCS/researchers
      Fragile Families and Child Wellbeing Study (FFCWS) DataThe FFCWS is a longitudinal birth cohort study of children in urban areas in the United States who were observed from birth to 15 years old; data from this study can be used to explore multiple types of disparities with confounders and mediators of outcomes.http://www.fragilefamilies.princeton.edu/
      Directions for access through a quick registration process can be obtained from the Fragile Families website.
      University of Michigan Institute for Social Research (ISR) and Inter-University Consortium for Political and Social Research (ICPSR)ISR contains the world’s largest archive of digital social science data; more than 7000 data collections are part of the archive, with up to 500 new collections added every year; well-trained staff provide user support using the extensive online data archive.https://www.icpsr.umich.edu/icpsrweb/ICPSR/index.jsp
      Federal Interagency Forum on Child and Family Statistics (Forum)The Forum is a collection of 22 federal government agencies that are involved in research and activities related to children and families; data from national data sets are available, along with assistance from expert staff.http://www.childstats.gov
      Centers for Disease Control and Prevention National Center for Health Statistics (NCHS)NCHS offers downloadable, public-use data files. Users of this service have access to data sets, documentation, and questionnaires from NCHS surveys and data collection systems.http://www.cdc.gov/nchs/
      Public-use data files are prepared and disseminated to provide access to the full scope of the data that allows researchers to manipulate the data in a format appropriate for their analyses.
      Jain. SMFM special report. Am J Obstet Gynecol 2018.

      Comment

      Racial/ethnic disparities in maternal morbidity and mortality rates are a major public health issue that must be addressed urgently. There is a clear need for an organized approach to identify and reduce these disparities and incorporate these efforts into the larger goal of the reduction of maternal mortality rates. The conference identified ways to decrease disparities in clinical care and areas where further research into maternal health disparities is needed. By shifting the focus from identifying the existence of disparities to the delineation of the provider and healthcare system factors that can be modified, we can work to lessen maternal morbidity and mortality rates and improve care for all women.

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