Adi Talwar
Entrance to the ER at North Central Bronx Hospital. The city's health system has taken notice of new threats to maternal health and established programs to address them.
The woman was bleeding profusely when she passed out in the street. Although nearing the end of a pregnancy, she had never gone to a prenatal clinic. She was bought to a New York City hospital in an ambulance. As a lifesaving measure, she received an emergency cesarean section and hysterectomy.
Another pregnant New Yorker whose placenta rested in an unusually low position (a condition known as placenta previa) was scheduled for a C-section. A week prior to the scheduled date she suddenly started to bleed severely.
A third woman went through months of an uncomplicated pregnancy and received excellent medical care. During delivery at the hospital, she suddenly felt faint. Her blood pressure dropped precipitously. Some portion of amniotic fluid entered into her blood stream. A cascade of events led to respiratory and cardiovascular compromise. Between 50 and 80 percent of the time this condition is fatal.
In all three cases—related to City Limits by a physician who didn’t disclose names or any other information about the patients—mother and child survived thanks to excellent care by the hospitals at which they were treated. Together, the episodes reveal important truths about the problem of severe maternal morbidity, or severe complications from pregnancy, which is still rare but becoming more common in New York: It can sometimes be prevented or mitigated by prenatal care. It can sometimes not be predicted at all. And hospital skill is critical to preventing a crisis from becoming a catastrophe.
A new study confirms not only the importance of hospital quality to mothers’ health but also the disparities New Yorkers encounter in accessing the best care. It finds that if self-identified black moms delivered at the same hospitals as self-identified white moms, nearly 1,000 black mothers in New York City could avoid every year a severe illness during their childbirth hospital stay. That’s because most mothers who self-identified as white delivered in city hospitals less likely to see what researchers call “severe maternal morbidity”—severe complications of pregnancy. Fewer than one-fourth of self-identified black mothers delivered at these hospitals, the research found.
“Our data suggest that many black women are going to the worst performing hospitals in New York City,” says Elizabeth Howell, vice chair of research in the Department of Obstetrics, Gynecology, and Reproductive Science at the Icahn School of Medicine at Mount Sinai and lead author of the 2016 study, which looked at 353,773 deliveries in 40 New York hospitals from 2011 through 2013. “We have to improve these hospitals.”
It’s not that hospitals are the only way to prevent maternal illnesses before, during or after childbirth. Conditions like diabetes, high blood pressure, and obesity can affect both mother and child health and should be managed early on in a person’s life. But the data suggest that some hospitals have figured out a better way to respond when something goes wrong.
A growing concern
Childbirth is difficult for most women. Both minor and moderate maternal morbidity – disease, illness, or other medical conditions – occur frequently and should be addressed seriously with expert care.
Severe maternal morbidity, however, is on another level. While not involving the death of the mother (a phenomenon known as maternal mortality), it encompasses such medical events as severe bleeding, seizures or convulsions, acute kidney failure, blood clot in the brain, heart attack, kidney failure and other conditions.
“These women were expecting one of the happiest days of their lives, the delivery of a baby, but are faced with a major and often scary complication occurring during their delivery,” Howell says. Many severe morbidity events during childbirth can be life threatening and “can really be traumatizing—for weeks or months or years,” she adds.
According to the New York City Department of Health and Mental Hygiene’s citywide Severe Maternal Morbidity surveillance system, there were approximately 120,000 deliveries in the city in 2012 and about 3,000 of them involved severe maternal morbidity. That represented an increase of more than 25 percent since 2008.
Severe maternal morbidity is in no way an illness unique to the poor or any particular segment of our city. “Some wealthy women can suffer from severe maternal morbidity. Many women who have undergone in vitro fertilization or ovum donation, and women pregnant over age forty are at elevated risk,” says Frederick Friedman, Jr., a physician who is Vice Chair and Associate Professor of Obstetrics, Gynecology, and Reproductive Science at Mount Sinai (who was not involved in the study).
The Howell study finds that severe maternal morbidity in New York City is far higher among self-identified black women (4.2 percent) than among self-identified white women (1.5 percent).
The 2016 NYC report found the rate of severe maternal morbidity for black, non-Latina moms with a college education to be higher than the rates for white non-Latina, Asian or Pacific Islander, Puerto Rican, or Latina women with a high school diploma and no college. Moms 19 years old and less and moms 40 years old and more were at greatest risk for severe maternal morbidity, and overall rates of severe maternal morbidity were highest for New York City moms living in very high poverty zip codes.
“In New York City, Black and Puerto Rican mothers are more likely to die or have complications during childbirth, when compared to white mothers,” says Dr. Aletha Maybank, the Deputy Commissioner for the Center for Health Equity of the Department of Health and Mental Hygiene. “This social injustice is driven by poverty and racism, which limit the ability of women of color to access quality healthcare, healthy foods, as well as, safe living and working conditions.”
The importance of hospitals
Previously it was generally thought that disparities in maternal morbidity and mortality were due to factors such as maternal education and nutrition, access to care and insurance. The Howell study confirmed that these factors—so-called “social determinants of health” —are very relevant to black-white disparities in morbidity numbers.
But in the past “very little attention” was paid to whether the hospital also makes a difference. The study finds that some hospitals do better than other hospitals, concluding that rates of severe maternal morbidity among NYC hospitals varied greatly (0.8 to 5.7 per 100 deliveries). [The study’s authors were not permitted to say which hospitals posted which scores.]
Howell’s study advances research on why severe maternal morbidity occurs and how to prevent it, explains Menachem Miodovnik, a physician at the Pregnancy and Perinatology Branch of the National Institute of Child Health and Human Development of the US National Institutes of Health. Crucially, it puts a focus on hospitals and how effectively individual hospitals provide care to individual patients during childbirth.
In particular, the finding that there would likely be “a significant reduction in morbidity for black women” if they were to deliver at the same hospitals as white women provides an important signpost for future research, Miodovnik says, noting the value of “quality improvement efforts, particularly at lower-performing NYC hospitals.”
Once a woman appears at the door of a hospital – whether or not she had been taking care of her health previously – certain hospitals excel, the study shows. So, when a woman who did not receive adequate prenatal medical care and who is obese and has hypertension and diabetes arrives at a hospital in labor – that situation is very, very challenging for any hospital. And some hospitals meet that challenge more effectively than others.
That could be because some hospitals have equipment others lack; or because they conduct more deliveries annually and so have greater experience (self-identified black mothers were six times more likely than self-identified whites to give birth at hospitals that had a low volume of deliveries [17.11 percent and 2.85 percent], according to the study); or because they are more skilled and better practiced in quality improvement methodologies and so might tend less to improvise crisis care; or for some additional reason.
Some hospitals might have developed checklists to guide what should be done, and even have additional standardized protocols in place, especially for women facing special risks like high blood pressure or severe diabetes. The medical teams at some hospitals may have practiced drills to learn how to act if a challenging medical complication appears and how to communicate effectively during a crisis. And some hospitals have better leadership than others, perhaps leadership with advanced training in quality improvement as applied to childbirth, or might gather data on what is going on with patients and use this data to continuously address gaps in performance.
In contrast, at some hospitals staff could be overworked and overwhelmed by the number and percentage of extraordinarily needy patients seen—patients who have not received adequate preconception and prenatal care. Some see a large percentage of patients with relatively less formal education (which may affect a patient’s ability to understand and follow doctors’ and nurses’ instructions and to use medications appropriately). Some hospitals may not be as well financed as others — in part because they conduct fewer clinical trials, receive less support from the National Institutes of Health or from private foundations, and benefit less from large private donations from major corporations and wealthy families.
The impact of an illness
As with any other threat to life, such as heart attack and cancer, severe maternal morbidity may impact the mom and her family over the long term. And as with other major medical events, physical changes to the human body constitute only part of the story. The experience of severe maternal morbidity “can affect woman’s psyche and her emotional well being,” Friedman says. And this, in turn, may affect such things as her effectiveness as a parent. The prevention of severe maternal morbidity is in the interest of society for many reasons.
“Severe maternal morbidity has a direct impact on the family, the medical community, the economy and society at large. It can leave families vulnerable when mothers have chronic and significant health problems,” Miodovnik says.
The effects of severe maternal morbidity can linger and persist over the course of decades. For example, “a woman who has experienced preeclampsia [a condition involving elevated blood pressure or swelling related to the collection of fluid within the body] is at elevated risk later in life for stroke, heart attack, and premature loss of life,” Friedman says. So these women “need to be monitored” and to receive medical care that is both regular and effective.
The DOHMH report also found the economic burden of severe maternal morbidity was “high” ($15,714, compared with $9,357 for deliveries with no severe maternal morbidity; and these numbers in no way represent long-term health expenditures by people or insurers).
“Clearly, if we can reduce severe maternal morbidity we will have cost savings” in the delivery hospitalization, where costs associated with severe maternal morbidity are twice those of normal deliveries, Howell says
In addition, providing competent and effective medical care to women of childbearing age impacts the financial costs associated with the long term health of the mother and her children. “Women with high blood pressure during pregnancy and delivery are at much higher risk for cardiovascular disease and stroke later in life” and women with a form of diabetes known as gestational diabetes during pregnancy are “at much higher risk for diabetes later in life,” Howell says.
Beyond the financial cost, maternal morbidity is connected with other birth-related problems like infant morbidity or maternal or infant mortality.
“There is frequently a link between maternal morbidity and increased risk of infant morbidity or mortality,” Miodovnik points out, saying that some “scenarios” may lead to “defects” of the kidneys and brain as well as sleep and feeding difficulties. And later in childhood there may be learning difficulties. Some of these health problems remain serious impediments in the lives of the newborns and their families for decades into the future and major sources of expense for insurers.
“The limited available data suggests that severe maternal morbidity is associated with higher rates of preterm birth” and thus with a diversity of health problems for some newborns, Howell says.
While the study was not about maternal mortality, it is relevant to note that the New York City Department of Health and Mental Hygiene recently reported that the black-white disparity in maternal mortality has increased. Their most recent data demonstrates that black women are twelve times more likely to suffer a pregnancy-related death than are white women. The increase in the black-white maternal mortality disparity was attributed to a 45 percent decline in maternal mortality among white women in New York City.
Prevention must start earlier than you think
Indeed, studies of childbirth conducted over the course of decades indicate that more than one third of severe events are preventable. But that doesn’t mean prevention is a simple task.
It is sometimes possible to predict that a woman is at elevated risk for severe maternal morbidity. According to the DOHMH report, local mothers with diabetes, heart disease, or high blood pressure were three times as likely to have severe maternal morbidity than moms with none of these conditions.
But some conditions are impossible to foresee. “Sometimes severe maternal morbidity develops in relation to previously identified risk factors and sometimes it develops without warning,” Friedman says. “It can be unpredictable. Sometimes it develops paroxysmally,” which means that a previously mild or moderate symptom might suddenly transform into a medical crisis.
What’s clear is that the earlier a woman and her doctor start focusing on her health, the better.
“Care for childbirth starts way before one gets pregnant. Pediatricians and even school health classes should be emphasizing that few things can substitute for proper health maintenance. As Benjamin Franklin said, ‘An ounce of prevention is worth a pound of cure,” Friedman says.
If nothing else, those early visits give doctors some intelligence to work with when things go wrong. “When a woman has not sought good preconception and prenatal care – for example, when she has had few or no visits to an obstetrician or midwife – one of the consequences is that her caregiver does not have all the information needed to address anything that might occur during the labor or childbirth,” Friedman adds.
The Howell study found 11.84 percent of black women attended five or fewer prenatal visits, compared with 3.39 percent of white women. It also revealed that in New York City a greater percentage of self-identified black women commence labor with poorer health than do self-identified white women: blacks post an obesity rate of 23.63 percent to whites’ 8.27 percent; chronic high blood pressure is present for 3.05 percent of black moms but only 0.73 percent of their white counterparts; black mothers are three times as likely to have diabetes and more than twice as likely to have asthma or chronic bronchitis.
To reduce risk of devastating and financially expensive events, not just prenatal but preconception care for women is important, Howell explains. Some women “get pregnant before having even seen their physician,” she says, and then may be faced with “out-of-control diabetes or hypertension during their pregnancy.”
“I think there is pretty wide consensus in medicine and public health that prenatal care is not a promising avenue to pick up the pieces that have fallen during a woman’s life course up to the time of pregnancy — Too little too late,” says Paula Braveman, a professor of Family and Community Medicine and Director of the Center on Social Disparities in Health at the University of California, San Francisco (UCSF).
On the basis of current evidence, she thinks “strategies aiming to improve early childhood conditions and development are the most promising” so that by the time a girl reaches childbearing age she will be better prepared to take care of her health and better able to make decisions about and manage a pregnancy. “A multigenerational approach may be best,” she says.
She pointed to the advantages of the “Parents and Children Thriving Together (PACTT): Two-Generation State Policy Network.” PACTT has been endorsed by The National Governors Association. PACTT is “one of the most promising strategies to improve maternal health,” although “the effects may require a generation or two to manifest.”
What is “great” about PACTT is that it recognizes that “you can’t improve conditions for children without improving conditions for adults” and that PACTT “takes an empowerment perspective.”
Further, “preventing unwanted pregnancy is another important, established strategy for maternal health,” Braveman says.
Directing women of childbearing age into adequate medical care is an area in which community groups, families, and the women themselves can make a positive contribution to prevention, experts say. And physicians and researchers should learn from community organizations and communities to better understand the barriers women face to getting healthcare.
The city reacts
It is not that quality improvement programs directed to childbirth in hospitals are lacking at present. For example, the Safe Motherhood Initiative sponsored by Merck for Mothers and the American Congress of Obstetricians and Gynecologists District II currently is bringing structured approaches to improving quality of care when hemorrhage, blood clots, and dangerous rises in blood pressure occur in New York State hospital delivery rooms.
Additional quality improvement programs are needed as is funding for them, particularly for lowest performing hospitals, experts say.
New York City has “recognized the challenges in maternal outcomes” and over the last several years has created programs, policies and task forces to reduce maternal mortality and morbidity, Miodovnik says, and has initiated programs to “specifically address the types of problems identified in the study.”
The problem is well known to the city’s health authorities, who have already taken some steps to address the problem. “New York City data highlights stark disparities along racial, ethnic and neighborhood poverty lines for maternal morbidity and we are working to reduce those gaps,” says Dr. Deborah Kaplan, assistant commissioner for the city’s Bureau of Maternal, Infant, and Reproductive Health in response to the study.
In response, the Department of Health and Mental Hygiene is supporting the Nurse-Family Partnership, an evidenced-based, nurse home-visiting program, “in high-need communities,” sending nurses to visit women in their homes every one to two weeks during pregnancy and throughout the child’s first two years of life.
Healthy Start Brooklyn, focused on central and eastern Brooklyn, works with the entire family, including fathers. And the By My Side Support Program pairs doulas (trained childbirth assistants) with pregnant women.
Also, the Department is developing a program of “Women’s Health Suites, housed within Neighborhood Health Action Centers. The plan is for these Suites to encompass risk-reducing behaviors during and after pregnancy as well as activities to support breastfeeding, encouragement of healthier eating, and resources for referral to medical and social service providers and birthing centers.
In addition, the Department also leads collaborative community and intergovernmental initiatives and, as well, partners with community organizations and health providers (doctors, nurses, midwives, and doulas) in Health Action Neighborhoods.
NYC’s public hospitals, meanwhile, say they are already taking steps to reduce maternal morbidity. They’ve adopted standards outlined in the American Congress of Obstetricians and Gynecologists’s Safe Motherhood Initiative and use team-based training of all labor and delivery staff. In addition, the city’s public hospitals have long screening mothers for depression before and after birth, “since depression can affect not just the mother, but also how parents care for their children,” explains, Machelle Allen, the physician who is Acting Chief Medical Officer, NYC Health + Hospitals. And the department supports “the need for further research in the areas of severe maternal morbidity and apparent racial disparities that exist in NYC,” she says.
Yet, additional policy solutions clearly are in order. All hospitals should have “protocols in place for high-risk conditions” and should “make sure the staff has the knowledge and equipment to deal with high-risk situations,” Howell believes. Additional equipment is also important. And a better system to let struggling hospitals learn from successful ones would help, she says.
Until all hospitals provide exceptional care, however, “we need to think about ways that we can refer women” to a more effective hospital setting before they are in labor, she adds.
The disparities in maternal morbidity and in the hospitals where mothers of different races are likely to seek care map broader problems of access and justice. A 2016 report by the Regional Plan Association has found that residents in poorer NY State counties, such as the Bronx, have much lower life expectancy than those in wealthier counties. Inequalities in healthcare remain serious problems in several facets of health.
Unequal access to high quality maternity care is “not in keeping with the way we think about our country,” Howell says. “This is a social justice issue.”
