Hello, I am Beth Ann Clayton, and I'd like to welcome you to Raising the Bar for Everyone, a Maternal Health Disparity Presentation. Our learning objective for this presentation is to discuss maternal health disparity and present opportunities for practice improvement. I have no financial relationships with any commercial interest related to the content of this activity, and I will not discuss off-label use during my presentation. We will begin by defining health disparity. Health disparity is the preventable differences experienced by socially disadvantaged populations in the burden of disease, injury, violence, or opportunities to achieve optimal health. The occurrence of these negative outcomes come at greater levels among certain populations or groups more than others. I had the opportunity to serve on the National Quality Forum for Maternal Morbidity and Mortality Committee. I'm bringing to light some of the evidence we know surrounding maternal health disparity. The CDC conducts national pregnancy-related mortality surveillance. This information facilitates understanding of risk factors and causes of pregnancy-related deaths in the United States. Maternal mortality is defined as death while pregnant or within one year of the end of the pregnancy from any cause related to or aggravated by the pregnancy. Birth data is used to calculate pregnancy-related mortality ratios, and the data is obtained from the National Vital Statistics System. Since the pregnancy mortality surveillance system was implemented, the number of reported pregnancy-related deaths in the United States has increased from 7.2 deaths per 100,000 live births in 1987 to 17.6 deaths per 100,000 live births in 2019. The reasons for the overall increase in pregnancy-related mortality are unclear. You can see in the most recent five years of data collection that the maternal mortality ratio has increased, peaking in 2021 with the onset of COVID. However, in 2022, we are starting to see a decline. In 2021, the research demonstrated that the maternal mortality rate for non-Hispanic black women was 2.6 times greater with 69.9 deaths per 100,000 live births compared to non-Hispanic white women with 26.6 deaths per 100,000 live births, or the Hispanic women with 28 deaths per 100,000 live births. Thus, the rates for black women were significantly higher than the rates for white and Hispanic women. In 2022, maternal mortality rates decreased significantly for black non-Hispanic women, white non-Hispanic, and Hispanic women. There was no observed decrease for Asian non-Hispanic women. In 2022, the maternal mortality rate for black women had decreased to 49.5 deaths per 100,000 live births, but still was significantly higher than the rates for white, Hispanic, and Asian patients. The maternal mortality rate for the black patients was 2.6 times higher than the rate for non-Hispanic white patients. Maternal mortality review committees are multidisciplinary committees that convene at the state or local level to comprehensively review deaths during or within one year of pregnancy. Recently, Trost et al. published a study that the aim was to review the deaths of United States maternal mortality data up to one year postpartum in over 36 states during the years of 2017 to 2019. Their study population included over 1,000 patients. Key findings from this study included that deaths occurred throughout the peripartum period during pregnancy, delivery, and up to one year postpartum. The leading cause of pregnancy-related death varied by race and ethnicity, and over 80% of the pregnancy-related deaths were determined to be preventable. In this study, they found that the leading causes of death included mental health conditions, hemorrhage, cardiac and coronary conditions, infection, embolic and thrombotic events, and cardiomyopathy. As you can see, there was a fairly even distribution of maternal deaths throughout the peripartum period. There was approximately 22% of the deaths occurred during the pregnancy, and 25% occurred the day of delivery or within the week after delivery. 23% of the deaths occurred in the 7 to 42 days postpartum, and the majority of the deaths occurred for 43 to 365 days postpartum. In order to improve maternal care, it's important to understand what the leading causes of mortality are for each racial or ethnic group. In this particular study, the non-Hispanic white patients had the highest mortality rate within the population of study at 46.6%. The leading cause of death for the non-Hispanic white patients were mental health disorders followed by hemorrhage. The second population to experience the most maternal mortality were the non-Hispanic black patients, and the leading cause of death for them was cardiac and coronary conditions followed by cardiomyopathy. For the Hispanic population, their leading cause of death was also mental health followed by hemorrhage. And for the non-Hispanic Asian patients, they represented the lowest amount of maternal mortality at 3%, and their leading cause of death was due to hemorrhage and amniotic fluid embolus. The Center for Disease Control and Prevention identified cases of severe maternal morbidity using an index of 18 indicators of a significant event or condition at delivery, such as blood transfusion, renal failure, and respiratory distress. These complications can be life-threatening, have long-term effects on a woman's health, and adversely affect her infant's health and well-being. Approximately 50,000 women in the United States experience severe maternal morbidity. Racial and ethnic minorities have a higher incidence of severe maternal morbidity, and the non-Hispanic black patients have the highest rate of morbidity indicators. Research has found that an increase in racial and ethnic disparities in severe maternal morbidity is not linked to maternal comorbidities. When odds were adjusted for comorbidities like anemia, obesity, hypertension, and blood transfusion, minority patients were still at a greater risk for severe maternal morbidity, with non-Hispanic blacks having the highest percentage at 44%, followed by Native Americans, Asian and Pacific Islanders, and then, finally, Hispanic Parturians. Do racial and ethnic disparities exist in obstetric anesthesia care? When evaluating post-Caesarean pain, it is noted that a pain score of 7 out of 10 or greater is more common among women identifying as black and Hispanic compared to those who identified as Caucasian or Asian. Despite having more severe pain, black and Hispanic women typically have fewer pain assessments performed and receive significantly less opioid pain medicine compared to non-Hispanic white women. Butwick et al. wanted to determine if racial and ethnic disparities exist in the mode of anesthesia for Caesarean delivery. Their study included over 50,000 women with varying racial and ethnic backgrounds. The study population, the majority of the patients did receive neuroxial anesthesia, and approximately 7% of the patients did undergo general anesthesia. In this study, they did demonstrate that African Americans received general anesthesia more often for Caesarean delivery compared to the other races. In fact, African Americans receive general anesthesia more than two times greater than the Caucasian patients. In this study, they went another step and did a sensitivity analysis investigating if disparity was present in specific Caesarean subpopulations. They looked at primary Caesarean delivery versus repeat Caesarean delivery, or Caesarean delivery without prior labor or induction of labor, and also in a population that was excluded women who received neuroxial anesthesia before general anesthesia. They found that in their sensitivity analysis, African Americans still had an increased odds for receiving general anesthesia compared to Caucasian women, and that Hispanic women also had a greater odds of receiving general anesthesia compared to Caucasian women, but less than the African American women. This study was an observational study design, so they were only able to determine association and not causality, but the authors did speculate possible etiologic factors for the disparities in the study, such as cultural barriers between minority patient and providers, that there was an overall mistrust between patients and providers, or a misunderstanding, that the patients may have had a limited interaction with health care systems or have limited health literacy, and that there was a lack of knowledge about health care services and anesthesia options related to labor and delivery. Limited data does suggest that minority patients may be more likely than Caucasian patients to refuse treatment, however, this is unlikely to fully explain all the health care concerns. It has been noted in previous studies that African American patients do have a higher incidence of non-reassuring fetal heart rate tracing as an indication for cesarean delivery, consistent with prior research suggesting that African Americans are at higher odds of cesarean delivery for the non-reassuring tracing compared to Caucasian patients. There are a variety of steps that anesthesia providers can take to help decrease maternal health disparity. Over the next sections of the presentation, we will review these strategies that you can consider incorporating into your practice. Various anesthesia organizations that govern our practice have released advice and initiatives to help decrease maternal health disparities, including the AANA, the ASA, and the Society of Obstetric and Anesthesia and Perinatology. You see in front of you the SOAP recommendations, including being a patient advocate, acknowledging your own personal implicit bias, collaborating with multidisciplinary care teams, acknowledging the community needs, accommodating patients' literacy and linguistic needs, being culturally competent, and using evidence-based protocols. Perhaps the first step to combating the maternal health disparities is educating providers on the disparity itself, as we did earlier in this presentation, and recognizing the impact of their own implicit bias on the care they deliver. During the active laboring process, parturians can quickly feel powerless while experiencing pain. In these moments of vulnerability, parturians should receive equal care. However, some parturians may experience unintentional differences in care rooted in implicit biases. Implicit bias has been defined as an unconscious or uncontrollable association with personal characteristics including age, race, and ethnicity, which negatively affect one's perceptions resulting in bias. These biases can cloud judgment, alter nonverbal behavior, and cause a disassociation between what one wishes to do or believe and the negative associations that ultimately prevail. Providers and staff should be educated on the presence of maternal health disparities and enlightened of their own own implicit bias. An opportunity to educate providers is via the Harvard Implicit Association Test or the Harvard IAT test. Completion of the Harvard IAT reveals individual hidden or subconscious bias facilitating understanding and encouraging change that can have impactful results. You can see the Harvard IAT implicit bias test link here below. I encourage you to take this test and take it on several different categories. It is very enlightening to recognize your own implicit biases. Another potential solution to decrease maternal health disparity is to establish the disparities dashboards. It is a recommendation from the Alliance of Innovation on Maternal Health Reduction of Peripartum and Racial Ethnic Disparities Bundle to develop dashboards which monitor outcomes stratified by race and ethnicity with regular dissemination to staff and leadership of this information. It is important though to establish systems to accurately document a patient's self-identified race and ethnicity because staff identification or utilizing surname analysis is often inaccurate. The American College of Obstetricians and Gynecologists conceptual bundle for a comprehensive approach to maternal health disparity suggests a proactive approach in combating the disparity. One way to achieve a comprehensive approach is by vigilantly tracking one's progress. This can be achieved by the utilization of an anesthesia specific outcomes dashboard or tracker that focuses on protruding outcomes based on race, ethnicity, and spoken language. You will also want to note the mode of delivery and whether the patient received labor analgesia or the type of anesthesia for a cesarean delivery. Another important step to decreasing maternal health disparity is to improve patient and provider communication. Communication is the cornerstone of quality care and patient safety and it is imperative that patients and their providers work together to determine the best treatment options. If the provider improves their cultural competency this will ultimately benefit the patient provider paradigm. It is important as providers that we take the time to hear and understand the proturient's feelings. This will allow the proturient and provider relationship to strengthen. We do not want to minimize proturient concerns or fears or pain that they are experiencing because this can result in proturient dissatisfaction and distrust in the providers and the health care system that's providing care to them. Patient-centered communication techniques can be used to encourage proturient participation and dialogue. Pregnant patients will feel better understood and respected by asking open-ended questions and allowing them time to respond. Once they do state their response it is helpful to restate what they have presented to you to confirm your understanding and also showing acceptance of their opinion. Consider your pace and your tone to give a welcoming dialogue and choose your vocabulary wisely trying to avoid complicated medical terms. You want to confirm understanding and give the patient another opportunity to ask questions. During conversations with maternal patients consider endorsing open communication using various models to build trust and rapport. The respect model is a communication framework used to build trust and rapport in health care emphasizing empathy, cultural competence, and understanding of the patient's perspectives. The AIDIC communication model serves as an acronym for acknowledging the patient by greeting them by name, introducing yourself, giving a duration of the time or the test that they may encounter, providing the patient a step-by-step explanation of what to expect, and then thanking them for allowing you to provide care. The AIDIC model will help increase the communication and hopefully leading to better patient satisfaction and outcomes. Nonverbal communication is powerful. Providers may unknowingly behave in a way or use body language considered offensive or belittling. This can discourage the maternal patient from asking questions or voicing concerns. Therefore, awareness of or mirroring nonverbal cues when interacting with maternal patients is important as it can lend to building perturbant trust in the provider. When possible, sit during your conversations. Sitting communicates to the patient a commitment to provide one-on-one care. Standing can be interpreted as wanting to flee the room or also dominating. Toledo et al. found that Spanish-speaking Hispanic perturrients were 12% less likely to receive an epidural than English-speaking Hispanic perturrients. Ultimately, for perturrients to be able to communicate effectively, they must be empowered to feel comfortable, represented, and understood. One way to promote perturrient comfort and communication is ensuring an interpreter is readily available if needed. While the use of an in-person or live video interpreter is ideal, a phone interpreter should be used at a minimum. Another possible solution to decreasing maternal health disparity is through shared decision-making. Shared decision-making is a process in which the provider shares with the patient all the relevant risk and benefit information on all treatment alternatives and that the patient shares with the provider all relevant personal information that might make one treatment or side effects more or less tolerable. This encourages shared decision-making, a partnership based on an open dialogue. Ways to promote patient participation are with the use of decisional aids such as pamphlets, brochures, and handouts or video that facilitate discussion. Perturrient participation should be encouraged and their decisions respected. Perturrients who are encouraged to engage in shared decision-making regarding epidural administration for labral analgesia are reported to have increased feelings of understanding and also higher satisfaction with the analgesia provided. Therefore, it's important to explain the epidural procedure and discuss the risks and benefits, allowing through this process the patient to ask questions. In addition, you want to provide clear expectations of the labor analgesia. For instance, explaining that the labor analgesia will decrease their pain but will not take it all away and also explaining that it's important for them to continue to have some movement so that when it comes time to push, they're able to participate actively in the delivery. Ways to foster this empowerment are ensuring the perturrient understands the variables and the ramifications of their decision. Providing the perturrient with decisional aids like a patient education handout on epidurals regarding labor analgesia treatment options can help decrease decisional conflict and result in the perturrient feeling empowered to participate in shared decision-making or make further inquiries. Providing these decisional aids ahead of needing the procedure will allow the patient to review the material frequently and also give them the opportunity to ask questions. This leads to a more prepared patient to make decisions with their providers. Similarly, once the perturrient has been given high-quality, evidence-based information and has arrived upon a decision regarding their care, their elected choice should be respected. Providers should refrain from coercion or attempts to change the perturrient's mind. Racially concordant care is associated with better patient-provider communication and improved patient satisfaction. Underrepresented minorities such as African-American or Black, Hispanic and Latino, or American Indian and Alaskan Native or Native and Hawaiian Pacific Islanders comprise 32% of the United States population, but only 8.6 of the anesthesia workforce. Therefore, promoting workforce diversity will help improve racially concordant care. As of 2022, 85% of certified registered nurse anesthetists self-identify as white, 4% as Asian Pacific Islander, and 3% as Hispanic, and 3% as non-Hispanic Black, and 3% as other or prefer not to answer, and 1% are multi-racial. Currently, there's approximately 6,000 anesthesia physician residents and their racial and ethnic diversity is higher than the certified registered nurse anesthetists. 56% of them identify as white, with 25% as Asian, and 8% as Hispanic, and 5.4% as Black, and 3.9% as multi-racial. Multidisciplinary collaboration of obstetric providers is recommended to facilitate reduction of severe maternal morbidity and mortality. Our various professional organizations encourage alliance of multidisciplinary obstetric care providers, including the AANA, ACOG, ASA, A1, the California Maternal Quality Care Collaborative, and the Society of Obstetric Anesthesia and Perinatology. The multidisciplinary collaboration allows you to prepare for maternal health emergencies by developing clinical pathways inclusive of implementing protocols with algorithms, develop rapid response teams, and perform drills. The American College of Obstetricians and Gynecologists suggests obstetric care providers use checklists and guidelines to standardize their care. When you standardize the care, you will decrease variation in care. We noted this at our hospital when we standardized our Pitocin administration protocol after cesarean delivery, and we saw that the hemorrhage incidence decreased in our minority patients by standardizing our care. Resources should be adopted during all phases of obstetric care, ensuring recognition and management of maternal health crisis using a multidisciplinary collaboration. Identified in this chart are resources for you to provide care. The American College of Obstetricians and Gynecologists and the California Maternal Quality Care Collaborative have provided multidisciplinary response plans to obstetric hemorrhage and severe hypertension. The AANA has developed analgesia and anesthesia for the obstetric patient guidelines. These are evidence-based practice guidelines for the maternal patient. In conclusion, further research is needed to illuminate underlying causes behind racial and ethnic disparities in anesthetic management in order to understand risks, cultural references, and access to care. Additional research will help drive development of target interventions to reduce racial and ethnic disparities in labor pain and management, and solutions will need to be included to strategize and focus on the patients, providers, and healthcare system levels. Educating oneself on these disparities is important. However, to truly make an impact, providers need to take continued action, such as self-identifying their own biases, using effective communication strategies to earn Parchurian's trust, empowering Parchurians to participate in shared decision-making, and collaborating with multidisciplinary colleagues to deliver quality, equitable care. I thank you for your time to listen to this important topic, and I hope that you are able to drive change at your individual facility and decrease maternal health disparity in your community.

maternal health disparities

racial mortality rates

implicit biases

healthcare communication

diversity in healthcare

systemic adjustments