PUB 460 Lecture 6 - Disparities in MCH.pdf

DISPARITIES IN MCH PUB 460 Dr. Gauri Desai Health Disparities • Health disparities are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations - CDC https://latinxphysiciansofca.org/...

DISPARITIES IN MCH PUB 460 Dr. Gauri Desai Health Disparities • Health disparities are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations - CDC https://latinxphysiciansofca.org/prevention-is-power/ Health Disparities “Health disparities adversely affect groups of people who have systematically experienced greater social or economic obstacles to health based on their racial or ethnic group, religion, socioeconomic status, gender, age, or mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.” CDC, Healthy People 2020 Health Disparities • Health disparities may exist by – • Area of residence • Race • Income • Education • Occupation • Sexual orientation • Gender identity • Others? Rural vs. Urban Disparities in MCH • Mortality rates from all the leading causes of deaths in the US are higher in rural areas — • Heart disease, stroke, cancer, unintentional injury, and chronic lower respiratory disease • Up to 40% of all U.S. counties - most of them rural - lack a qualified childbirth provider • These are places where there is not one obstetrician, midwife, or family physician attending births in the entire county Kozhimannil, K. B., J. D. Interrante, C. Henning-Smith and L. K. Admon (2019). "Rural-urban differences in severe maternal morbidity and mortality in the US, 2007–15." Health affairs 38(12): 2077-2085; Kozhimannil, K. B., C. Henning-Smith, P. Hung, M. M. Casey and S. Prasad (2016). "Ensuring access to high-quality maternity care in rural America." Women's Health Issues 26(3): 247-250. Rural vs. Urban Disparities in MCH • “Access to Maternal Health Care in Rural Communities: A Patient's Personal Story” video [5:04]: https://www.youtube.com/watch?v=IuacmIKWDLw&ab_channel=C MSHHSgov • “Why Rural Health Care Is Failing New Moms” video [5:08]: https://www.youtube.com/watch?v=5qTk6GAGre4&ab_channel=W allStreetJournal Rural vs. Urban Disparities in MCH Compared to urban residents, rural residents – Rural vs. Urban Disparities in MCH • Severe maternal morbidity refers to potentially life-threatening complications or the need to undergo a lifesaving procedure during or immediately following childbirth • Severe maternal morbidity and mortality increased among both rural and urban residents in the study period, from 109 per 10,000 childbirth hospitalizations in 2007 to 152 per 10,000 in 2015 • When controlled for sociodemographic factors and clinical conditions, rural residents had a 9% greater probability of severe maternal morbidity and mortality, compared with urban residents Kozhimannil, K. B., J. D. Interrante, C. Henning-Smith and L. K. Admon (2019). "Rural-urban differences in severe maternal morbidity and mortality in the US, 2007–15." Health affairs 38(12): 2077-2085. Rural vs. Urban Disparities in MCH Predicted marginal probabilities used specified covariate values based on mean values or proportions in the overall sample per delivery year, including maternal age at delivery, insurance payer, race/ethnicity, bottom quartile of income (explained in the notes to exhibit 1), hospital region, cesarean delivery, substance use disorder, depression, HIV/AIDS, pulmonary hypertension, lupus, chronic kidney disease, chronic heart disease, diabetes, chronic hypertension, and chronic respiratory disease. Predicted marginal probabilities were calculated from estimates derived from available data (through the third quarter of 2015) and predicted out (from the third quarter of 2015 on) following trends estimated from available data. The vertical line distinguishes estimated from predicted probabilities. Predicted marginal probabilities among rural and urban residents were significantly different at p values less than 0.05 for years 2009–15 Kozhimannil, K. B., J. D. Interrante, C. Henning-Smith and L. K. Admon (2019). "Rural-urban differences in severe maternal morbidity and mortality in the US, 2007–15." Health affairs 38(12): 2077-2085. Rural vs. Urban Disparities in MCH • Rural areas have a higher burden of maternal mortality in all racial groups Maternal Mortality Rates by Levels of Urbanization, United States, 2013-2017 Source: Data derived from the National Vital Statistics System. Note: Metropolitan (urban) counties include: (1) large central metro (inner-city counties of MSAs (metropolitan statistical areas) of ≥1 million population), (2) large fringe metro (suburban counties of MSAs of ≥1 million population), (3) medium metro (counties of MSAs of 250,000999,999 population), (4) small metro (counties of MSAs with <250,000 population). Nonmetropolitan (rural) counties include: (5) micropolitan (large rural) counties in micropolitan statistical areas (population 10,000 to 49,999), (6) non-core (small rural) nonmetro counties that are not in a micropolitan statistical area. For American Indians and Alaska Natives, the mortality rates are shown for all metro areas combined, large rural areas, and small rural areas. Singh, G. K. (2021). "Trends and social inequalities in maternal mortality in the United States, 1969-2018." International Journal of Maternal and Child Health and AIDS 10(1): 29. Hospital Closures in Rural Areas • Using national data, this study found that 9% of rural counties experienced the loss of all hospital obstetric services in the period 2004–14. • In addition, another 45% of rural US counties had no hospital obstetric services at all during the study period. • That left more than half of all rural US counties without hospital obstetric services. Hung, P., C. E. Henning-Smith, M. M. Casey and K. B. Kozhimannil (2017). "Access to obstetric services in rural counties still declining, with 9 percent losing services, 2004– 14." Health Affairs 36(9): 1663-1671. Hospital Closures in Rural Areas • Compared to urban hospitals, rural facilities serve a higher proportion of low- and moderate-income families • These families are more likely to be eligible for Medicaid coverage or subsidized Marketplace coverage through the Affordable Care Act • Medicaid income eligibility thresholds for pregnant women vary significantly by state — ranging from 138% to 380% of the federal poverty level (2017 data) • >50% of rural births covered by Medicaid Hung, P., C. E. Henning-Smith, M. M. Casey and K. B. Kozhimannil (2017). "Access to obstetric services in rural counties still declining, with 9 percent losing services, 2004–14." Health Affairs 36(9): 1663-1671. Hospital Closures in Rural Areas • Reimbursement rates for birth under Medicaid are approximately half of what private health plans pay • Especially difficult for rural providers in low-volume settings – • Need to cover the fixed costs associated with maintaining an obstetrics unit • Need to address complex and challenging cases • Medicaid coverage ends sixty days postpartum • Thus, more than half of all Medicaid beneficiaries experience health insurance coverage gaps shortly after childbirth Hung, P., C. E. Henning-Smith, M. M. Casey and K. B. Kozhimannil (2017). "Access to obstetric services in rural counties still declining, with 9 percent losing services, 2004–14." Health Affairs 36(9): 1663-1671. Hospital Closures in Rural Areas “No services”: Counties that had no in-county hospital obstetric services in the study period “Continual services”: Counties that had at least one in-county hospital that provided obstetric services in the study period “Full closure”: Counties in which all in-county hospital obstetric services closed during the study period Hung, P., C. E. Henning-Smith, M. M. Casey and K. B. Kozhimannil (2017). "Access to obstetric services in rural counties still declining, with 9 percent losing services, 2004– 14." Health Affairs 36(9): 1663-1671. Implications for Rural Areas To address the specific needs of rural communities – • Policies must offer funding for financial and logistical support to hospitals. • These may include low-volume payment adjustments, • Resources and training for emergency obstetrics, • Financial incentives for collaboration across rural communities and with higher-acuity facilities in urban settings • Nonclinical support for birth and the postpartum period, including doulas, community health workers, and lactation consultants • Extending Medicaid coverage beyond 60 days post partum is key to improving MCH outcomes Hung, P., C. E. Henning-Smith, M. M. Casey and K. B. Kozhimannil (2017). "Access to obstetric services in rural counties still declining, with 9 percent losing services, 2004– 14." Health Affairs 36(9): 1663-1671. Federal and State Policies to Support Maternity Care for Rural Areas 1. Federal Policy Efforts to Address Workforce Shortages • Improving Access to Maternity Care Act is a bill working its way through Congress • Tasks the Health Resources and Services Administration with identifying maternity care workforce shortage areas across the country • Loan forgiveness programs through the National Health Services Corps, which may incent maternity care clinicians to practice in those areas Kozhimannil, K. B., C. Henning-Smith, P. Hung, M. M. Casey and S. Prasad (2016). "Ensuring access to high-quality maternity care in rural America." Women's Health Issues 26(3): 247-250. Federal and State Policies to Support Maternity Care for Rural Areas 2. Federal Policy Efforts to Improve Maternal Care Quality • Quality Care for Moms and Babies Act – proposed bill that creates a core set of maternal and infant healthy quality measures to better track the quality of care delivered to pregnant women and infants • The existing quality measures for maternity and newborn care are not widely used or reported, hence the need for uniform quality measures • The bill ensures funding for maternity and infant care quality collaboratives that will focus on improving the care delivered to pregnant women and infants throughout the country Kozhimannil, K. B., C. Henning-Smith, P. Hung, M. M. Casey and S. Prasad (2016). "Ensuring access to high-quality maternity care in rural America." Women's Health Issues 26(3): 247-250. Federal and State Policies to Support Maternity Care for Rural Areas 3. Medicaid Policy – State level efforts • State Medicaid programs need to ensure an adequate supply of providers and reduce financial barriers to accessing evidence-based maternity services through • Coverage, • Benefits, • Reimbursement rates, • Payment policy, and • Managed care arrangements Kozhimannil, K. B., C. Henning-Smith, P. Hung, M. M. Casey and S. Prasad (2016). "Ensuring access to high-quality maternity care in rural America." Women's Health Issues 26(3): 247-250. Racial Disparities in MCH • Maternal mortality in the US declined by 68% between 1969 and 1998; however, the maternal mortality rate nearly doubled between 1999 and 2018 • Maternal mortality has been high in Black women compared to women of other races Singh, G. K. (2021). "Trends and social inequalities in maternal mortality in the United States, 1969-2018." International Journal of Maternal and Child Health and AIDS 10(1): 29. Trends in Maternal Mortality by Race, United States, 1969-2018. Source: Data derived from the National Vital Statistics System. Racial Disparities in MCH Hoyert, 2022., Maternal Mortality Rates in the United States, 2020 Racial Disparities in MCH • Several underlying factors lead to the observed disparities – 1. Pre-pregnancy care 2. Prenatal factors 3. Quality of Hospitals 4. SES factors 5. Racism and structural racism Oribhabor G I, Nelson M L, Buchanan-Peart K R, et al. (July 15, 2020) A Mother's Cry: A Race to Eliminate the Influence of Racial Disparities on Maternal Morbidity and Mortality Rates Among Black Women in America. Cureus 12(7): e9207. DOI 10.7759/cureus.9207 Racial Disparities in MCH 1. Pre-pregnancy care • Optimizing preconception care improves pregnancy outcomes by improving women's overall physical health and reproductive planning • Black women have higher rates of obesity, hypertension, diabetes, and chronic disease • These comorbidities are linked to adverse maternal outcomes • Emphasizes the need for preconception care in this population Oribhabor G I, Nelson M L, Buchanan-Peart K R, et al. (July 15, 2020) A Mother's Cry: A Race to Eliminate the Influence of Racial Disparities on Maternal Morbidity and Mortality Rates Among Black Women in America. Cureus 12(7): e9207. DOI 10.7759/cureus.9207 Racial Disparities in MCH 2. Prenatal Factors • Early and adequate prenatal care promotes healthy pregnancies by screening and managing the risk factors and promoting healthy behaviors during pregnancy • Fewer prenatal visits are associated with poorer outcomes of pregnancy, such as low birth weight, premature birth, and infant mortality • No or few prenatal visits are associated with maternal mortality and severe maternal morbidity • High cost of care, insurance availability, commuting challenges, lack of culturally competent care are barriers to timely and adequate prenatal care Oribhabor G I, Nelson M L, Buchanan-Peart K R, et al. (July 15, 2020) A Mother's Cry: A Race to Eliminate the Influence of Racial Disparities on Maternal Morbidity and Mortality Rates Among Black Women in America. Cureus 12(7): e9207. DOI 10.7759/cureus.9207 Racial Disparities in MCH 2. Prenatal Factors • 2012 data – Initiation of prenatal care in the first trimester varies across racial groups – • White – 79% • Asian– 78% • Mixed race – 71% • Hispanic – 69% • Black – 64% • Native Hawaiian/other Pacific Islander – 55% • American Indian/Alaska Native – 59% Oribhabor G I, Nelson M L, Buchanan-Peart K R, et al. (July 15, 2020) A Mother's Cry: A Race to Eliminate the Influence of Racial Disparities on Maternal Morbidity and Mortality Rates Among Black Women in America. Cureus 12(7): e9207. DOI 10.7759/cureus.9207 Racial Disparities in MCH 3. Quality of Hospitals • Obstetrical complications are sensitive to the quality of care provided at delivery Oribhabor G I, Nelson M L, Buchanan-Peart K R, et al. (July 15, 2020) A Mother's Cry: A Race to Eliminate the Influence of Racial Disparities on Maternal Morbidity and Mortality Rates Among Black Women in America. Cureus 12(7): e9207. DOI 10.7759/cureus.9207 Racial Disparities in MCH 3. Quality of Hospitals • Obstetrical complications are sensitive to the quality of care provided at delivery, yet limited research on race/ethnicity and quality of hospitals • Racial/ethnic minority women often deliver in lower-quality hospitals • If black women gave birth in the same hospitals as white women, nearly 1000 black women would be able to prevent severe and detrimental incidents during labor hospitalizations, decreasing the frequency of black maternal morbidity from 4.2% to 2.9% Oribhabor G I, Nelson M L, Buchanan-Peart K R, et al. (July 15, 2020) A Mother's Cry: A Race to Eliminate the Influence of Racial Disparities on Maternal Morbidity and Mortality Rates Among Black Women in America. Cureus 12(7): e9207. DOI 10.7759/cureus.9207 Racial Disparities in MCH 4. SES factors • Social determinants of health are thought to be the driving factor behind the observed disparities • Unequal distribution of resources and power, including commodities, facilities, giving rise to unequal social, economic, and environmental circumstances for communities of different races/ethnicities • African Americans are at a poverty rate of 20.8%, Non-Hispanic whites at 8.1% • Rates of health insurance coverage, differences in access to healthcare, work in low-income paying jobs with no health benefits Oribhabor G I, Nelson M L, Buchanan-Peart K R, et al. (July 15, 2020) A Mother's Cry: A Race to Eliminate the Influence of Racial Disparities on Maternal Morbidity and Mortality Rates Among Black Women in America. Cureus 12(7): e9207. DOI 10.7759/cureus.9207 Racial Disparities in MCH If social determinants of health are the root cause of the race-based disparities in maternal health, why do college-educated Black women have higher maternal mortality rates than High-school educated White women? Racial Disparities in MCH Source: https://www.cdc.gov/reproductivehealth/maternal-mortality/disparities-pregnancyrelated-deaths/infographic.html Racial Disparities in MCH 5. Racism • Implicit bias – “thoughts and feelings that exist outside of conscious awareness and subsequently can affect human understanding, actions, and decisions unknowingly” • Also defined as the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner • Directly correlated with lower quality of care for patients and may be activated under stressful working conditions Saluja, B. and Z. Bryant (2021). "How implicit bias contributes to racial disparities in maternal morbidity and mortality in the United States." Journal of Women's Health 30(2): 270-273. Racial Disparities in MCH 5. Racism • Implicit bias affects health care providers’ perceptions and decisions, creating inequalities in access, patient–provider interactions, treatment decisions, and health outcomes • Some health care providers still hold false beliefs about biological differences between Black and White individuals that increase implicit bias; beliefs include that compared to White people, Black people have – • Less sensitive nerve endings, • Thicker skin, • Stronger bones • Cause health care providers to rate Black patients’ pain lower and results in less-appropriate treatment recommendations Saluja, B. and Z. Bryant (2021). "How implicit bias contributes to racial disparities in maternal morbidity and mortality in the United States." Journal of Women's Health 30(2): 270-273. Racial Disparities in MCH 5. Racism • Implicit bias also can affect how providers communicate with patients • Subtle racial biases may be expressed in such ways as approaching patients with a condescending tone • This decreases the likelihood that patients will feel heard and valued by their providers • Another example is recommending different treatment options for patients based on assumptions about their treatment adherence capabilities or presumed health conditions • Patients of these providers report poorer satisfaction ratings and greater difficulty understanding or following recommendations, which can perpetuate biases held by the provider Saluja, B. and Z. Bryant (2021). "How implicit bias contributes to racial disparities in maternal morbidity and mortality in the United States." Journal of Women's Health 30(2): 270-273. Racial Disparities in MCH 5. Racism • Structural racism: “a system where public policies, institutional practices and cultural representations work to reinforce and perpetuate racial inequity” – Aspen Institute https://www.bridgespan.org/insights/library/organizational-effectiveness/senior-leaders-role-in-building-race-equity Taylor, J. K. (2020). "Structural racism and maternal health among Black women." Journal of Law, Medicine & Ethics 48(3): 506-517. Racial Disparities in MCH 5. Racism • Structural racism and health care delivery - Underlining the differences in treatment practices and respect for bodily autonomy for white women and back women are institutional practices that perpetuate racial inequity as a form of structural racism • Black women are more likely to be given cesarean sections (~ rate of 40%) compared to white women (~ rate of 29%) • “Listening to Mothers” survey by National Partnership for Women and Families, 2018 – Black women more likely to report unfair treatment and discrimination within the health care system • Structural racism and Medicaid- Some states have adopted Medicaid expansion under the Affordable Care Act by adjusting the income eligibility • Most of the states that failed to expand Medicaid are concentrated in the South and have large concentrations of people of color Taylor, J. K. (2020). "Structural racism and maternal health among Black women." Journal of Law, Medicine & Ethics 48(3): 506-517. Racial Disparities in MCH 5. Racism • YouTube video [10:51]: https://www.youtube.com/watch?v=rOAPwSiu8Wg&ab_channel=PBSNewsHour YouTube video (watch this later) [6:28]: https://www.youtube.com/watch?v=VYc-Eq-vDuA&ab_channel=HealthcareTriage Recommendations to Address Racial Disparities in MCH • Cultural humility – Cultural humility principles emphasize that providers should aim to connect with patients instead of assuming expertise on the patient’s race, culture, or ethnicity and how those relate to the patient’s health • More diverse, culturally competent health care workforce • Antiracism and bias trainings should also be integrated with additional professional trainings • Medicaid expansion Taylor, J. K. (2020). "Structural racism and maternal health among Black women." Journal of Law, Medicine & Ethics 48(3): 506-517. Saluja, B. and Z. Bryant (2021). "How implicit bias contributes to racial disparities in maternal morbidity and mortality in the United States." Journal of Women's Health 30(2): 270-273. Question Bank • What are some of the barriers to accessing maternal care for rural residents? List any two. • What are some of the underlying reasons that lead to racial disparities in maternal health? Elaborate on any two. Housekeeping  Short HW and case study HW open – due 9/21, 1:00 pm