1. OBSTETRIC COMPLICATIONS DURING LABOR AND DELIVERY: ASSESSING ETHNIC DIFFERENCES IN CALIFORNIA Sylvia Guendelman, Ph.D. Dorothy Thornton, Ph.D. Jeffrey Gould, M.D., M.P.H. Nap Hosang MD, MPH, MBA University of California, Berkeley Expecting Something Better: A Conference to Optimize Maternal Health Care Jacobs Institute May 18,19 2005

2. The Burden of Morbidity During Labor and Delivery Although few women die in childbirth, a recent national study conducted by CDC showed that one out of four women experience an obstetric complication during Labor and Delivery such as pre-eclampsia, eclampsia, hemmorhage, infection, a major laceration or other obstetric trauma. Danel, Berg, Johnson & Atrash AJPH, 2003, 93:631-634 Normal Pregnancy Severe Morbidity MorbidityNear MissDeath

3. Defining Maternal Morbidity A maternal morbidity is a physical complication or condition caused by the pregnancy itself or by its management that is not considered normal during delivery or that cannot be adequately managed without detrimental health effects. A maternal morbidity is a physical complication or condition caused by the pregnancy itself or by its management that is not considered normal during delivery or that cannot be adequately managed without detrimental health effects.

4. Maternal Morbidity During Labor and Delivery 1. Is a new surveillance indicator in Healthy People 2010 2. Data are needed to assess health disparities 3. Women of color contribute disproportionately to births in the US, yet population data by race/ethnicity are not available, especially for non-Black women

5. Examining Ethnic Disparities in Maternal Morbidities in California Purpose: Used linked hospital discharge and birth records data to: 1) Compare obstetric complications during labor and delivery among white non-Latina, Black, Asian and Latina women who delivered in California hospitals during 1996-98 2) Compare ethnic differences on three indicators sensitive to the quality of intrapartum care: postpartum hemmorhage, major puerperal infections and major lacerations 3) Suggest strategies for change

6. Conceptual Framework Socio-demographic characteristics One or more maternal morbidities Intrapartum care sensitive conditions Access to Care Age at delivery Age at delivery Parity Parity Education Education Prenatal care payment source Prenatal care payment source public or self pay low SES vs. public or self pay low SES vs. private moderate/high private moderate/high Prenatal care initiation Prenatal care initiation Quality of obstetric care Quality of obstetric care

7. Deliveries in California, 1996-98 n=1,426,854 Latina WhiteBlacksAsians 35% 51% 7% 6.9%

8. Table 1: Rates of At Least One Maternal Morbidity and the Three Most Common Maternal Morbidities during Labor and Delivery by Race/Ethnicity. All DeliveriesLatinaBlackAsianWhite 1,507,275723,821101,39698,219503,418 At least One 20.91%19.57%24.15%21.34%21.28% Most Common Major lacerations 4.23% GU Infections 3.52% GU Infections 5.47% Major Lacerations 6.32% Major lacerations 4.87% 2 nd Most Common GU Infections 3.38% Major lacerations 3.47% Pre- eclampsia/ Eclampsia 3.88% Post- partum Hemorrhage 2.70% GU Infections 2.99% 3 rd Most Common Pre- eclampsia/ Eclampsia 2.94% Pre- eclampsia/ Eclampsia 2.95% Other Infections 3.42% Puerperal Conditions 2.22% Pre- eclampsia/ Eclampsia 2.89%

9. Table 2: Odds of One or More Maternal Morbidities During Labor and Delivery WhiteAsianLatinaBlack Observed ORRef 1.00 0.99-1.02 0.92 0.91-0.93 1.18 1.16-1.20 Adjusted OR**Ref 0.95 0.93-0.96 0.97 0.96-0.98 1.25 1.23-1.27 **log odds obstcmplany=const+black+asian+Latina+age+par1+seslow+education +kotelpnc+lowqual+hiqual

10. Table 3: Intrapartum Care-Sensitive Conditions Postpartum Hemorrhage PopulationWhiteAsianLatinaBlack Adjusted OR Ref 1.06 1.02-1.11 1.01 0.98-1.04 1.04 0.99-1.08 Major Puerperal Infections PopulationWhiteAsianLatinaBlack Adjusted OR Ref 1.16 1.08-1.25 1.19 1.13-1.24 2.35 2.21-2.49 Major Lacerations 3rd and 4th Degree PopulationWhiteAsianLatinaBlack Adjusted OR – vag. delivery Ref 1.22 1.19-1.26 0.91 0.89-0.93 0.63 0.60-0.66

11. Conclusion 1. Considerable burden of morbidity for all women during L & D: One out of five deliveries had at least one complication. 2. Black women experience more aggregate morbidities, while Asian and Latina women experience fewer aggregate morbidities compared to white women.

12. Conclusion 3. Asian women however stand a higher risk of sub-optimal intrapartum care: higher odds of lacerations, puerperal infections and post partum hemorrhage compared to white women. Possible risk factors: interracial marriages, increased BMI, bigger babies, GDD, provider, system-level factors. 4. All women of color show excess risk of puerperal infections. 5. Health disparities can mean decreased quality of life, loss of economic opportunities and feelings of discrimination.

13. Table 4: Rates of at Least One Severe Maternal Morbidity During L&D by Race/Ethnicity All DeliveriesLatinaBlackAsianWhite 1,507,275723,821101,39698,219503,418 13.1%12.1%14% 13.4% *Based on reduced list of OB complications

14. Can We Expect Something Better? For the amount of investment in prenatal care and OB care can we reduce the rates of morbidities and severe morbidities?  How far down can we go?  What will it take?

15. A. Public Health Recommendations 1. Raise awareness among providers, policy makers and women themselves about the level of aggregate morbidity prevailing during L & D. 2. That we continue to strengthen surveillance of maternal health to monitor changes across populations and care practices nationally, across states and in diverse localities.

16. B. Research Recommendations 1. Inquire about women’s perceptions of these morbidities, the impact on the quality of women’s lives and their satisfaction with the obstetric care received. Future PRAMS surveys could include questions that address these substantive issues. 2. Through clinical, laboratory and epidemiological research, identify best care practices and protocols that could be made available to reduce infections. Ensure group B Streptococcal infection protocols Ensure group B Streptococcal infection protocols ACOG develop guidance on appropriate timing for antibiotic prophylaxis after rupture of membranes ACOG develop guidance on appropriate timing for antibiotic prophylaxis after rupture of membranes Assess variation in efficiency of protocols by ethnicity Assess variation in efficiency of protocols by ethnicity

17. C. Provisions of Care 1. Focus on intrapartum care sensitive conditions to assess ways of improving obstetric care during labor and delivery, particularly for minority women. Hospitals should review cases of intrapartum complications to Hospitals should review cases of intrapartum complications to identify care practices as starting points for continuous quality identify care practices as starting points for continuous quality improvement. improvement. That these practices be included as quality markers for the That these practices be included as quality markers for the Joint Commission on Accreditation of Healthcare Joint Commission on Accreditation of Healthcare Organizations JCAHO. Organizations JCAHO. 2. With respect to prevention of major lacerations, 2. With respect to prevention of major lacerations, researchers, physicians and other providers should researchers, physicians and other providers should consider risk factors in the perineum that makes consider risk factors in the perineum that makes tearing more likely. tearing more likely.