Experts Are Digging Deeper Into What Exactly Drives Racial Inequities in Pregnancy Outcomes
In the United States, approximately 700 women die as a result of pregnancy or its complications every year. And within this 700, major disparities exist. Black birthing people, according to the Centers for Disease Control and Prevention, had significantly more pregnancy-related deaths per 100,000 births than did white and even Hispanic and Asian/Pacific Islander birthing people. These disparities persisted when accounting for high levels of education, in states with low pregnancy-related mortality, and across age groups.
As part of the new Health Equity Accelerator at Boston Medical Center Health System, experts wanted to delve further into the data, to not only show these disparities but to see why, in an effort to effect change.
Starting in the fall of 2021, as part of the research that helped launch the Health Equity Accelerator, Boston Medical Center (BMC) convened a team of more than 20 experts in maternal-infant health, including researchers, physicians, nurses, community liaisons, and operations leaders from Obstetrics & Gynecology, Pediatrics, and Family Medicine. The team aimed to develop a plan for how BMC would reduce its own inequities in maternal-infant outcomes—uniquely looking inward at its own protocols, outcomes, and BMC patient perceptions with the idea that BMC must name and understand its own faults and shortcomings to best address them.
Looking at inward at racial disparities driving pregnancy outcomes
One of the group's first objectives was to solicit input from within its own cohort of patients on how they perceive pregnancy care at BMC, specifically. BMC's patient insights manager helped craft a short survey that was completed by more than 50 patients who had received prenatal, delivery, and/or postpartum care at BMC in the last five years. The survey’s results showed some racial disparities in patient experience. For example, Black patients were less likely to report they "almost always feel like [they are] treated with empathy and respect."
"In the course of a few months, the team has been able to better understand what's driving inequity in pregnancy and start putting together a plan."
"This journey so far with the Accelerator has been a rapid one toward embracing humility and acknowledging the role that we all play as providers, and nurses, and doulas, and MAs, and unit coordinators toward what we see in our patients. And they deserve transformation," said Christina Yarrington, MD, FACOG, about the intensive research process in a panel discussion about the Accelerator.
Yarrington co-leads the Accelerator's equity in pregnancy initiative along with Tejumola Adegoke, MD, MPH, an obstetrics & gynecology physician and director for Equity & Inclusion at BMC.
After a comprehensive review of maternal-infant health outcomes for BMC patients by race, the group decided to focus on two key metrics where there are disparities between Black and white patients at BMC:
- The rate of severe maternal morbidity (SMM), a CDC-defined measure that tracks severe complications during labor and delivery, such as receiving a blood transfusion, acute kidney failure, and sepsis
- The prevalence of small for gestational age (SGA) birthweight, a measure of baby’s health. SGA reflects a weight under the 10th percentile for the gestational age at which they are born, thus captures both premature and term underweight babies.
After adjusting for substance use disorder (which disproportionately affects white patients at BMC), the SMM rate is nearly twice as high for Black versus white patients, and the SGA rate is more than one and a half times higher for Black newborns.
Preeclampsia disparities among pregnant Black BMC patients
The group worked closely with the BMC System Analytics team to use internal data to understand the drivers of inequity for both SMM and SGA. They found that 75% of the inequity in SMM rates between Black and white patients was associated with complications of hypertensive disorders of pregnancy: preeclampsia and gestational hypertension. Black patients were more likely to have these conditions (17% of Black patients compared with 12% of white patients), on par with national statistics about pregnancy hypertension.
Additionally, Black patients at BMC with these conditions were two and a half times more likely to suffer SMM compared to their white counterparts. In other words, when they do have preeclampsia, it leads to more serious complications during labor for Black patients.
Preeclampsia is a condition in which the blood pressure of a pregnant person progressively increases, putting the pregnant person at risk of stroke, seizure, and other organ damage. As Elena Mendez-Escobar, executive director of the Heath Equity Accelerator, notes, preeclampsia is potentially life-threatening, and the only cure is delivery of the baby. Depending on when preeclampsia arises, definitive treatment of the pregnant patient needs to be balanced against the harm of possible premature delivery for the baby.
"[With preeclampsia], there is a series of decisions that needs to be made very quickly … What we know is that small variations in this time can really increase the risk of complications," Mendez-Escobar explained during the same panel. "We're starting to see in our data that this decision-making is taking longer with our Black patients. We need to fully understand why that is."
The team is continuing to delve into clinical data to understand how BMC team members make decisions about length of inductions, the decision to transition to C-section, and whether unconscious bias may be impacting this decision-making. In addition, the Accelerator is already planning to implement actionable changes that could help close these gaps.
"They are actions that will help with the interactions between patient and provider," Mendez-Escobar said. "For example, expanding our Birth Sisters program and implementing more remote monitoring of hypertension, since this is a source of really a lot of the complications."
Drivers of inequities in babies born small for gestational age
Unlike SMM, hypertensive disorders of pregnancy did not seem to be associated with any inequity in SGA rates between Black and white patients, which led the team to believe that the drivers of inequity for SMM and SGA are distinct.
Analysis revealed that SGA seemed to be highly linked with Medicaid coverage, suggesting that low-income or poverty may be a driver of SGA. Black patients are more likely than white patients to be covered by Medicaid, due to structural inequities impacting income and wealth, resulting in a large portion of the SGA inequity being linked to Medicaid coverage.
Additional analysis revealed several risk factors that are linked with both Medicaid coverage and higher SGA rates for Black patients, such as mental health disorders (especially depression), SUD and alcohol use during gestation, homelessness, and low BMI.
"In the course of a few months, the team has been able to better understand what's driving inequity in pregnancy and start putting together a plan," said Mendez-Escobar.
The team aims to innovate in clinical care with the help of community partners. Specifically, to address inequities in SGA, BMC will work with community partners to develop upstream interventions to improve economic opportunity for Black residents and connect Black pregnant patients with the care and resources they need during the prenatal phase, such as therapy, food, and housing.
Further research endeavors in maternal and child health
Just as the group has identified a set of foundational interventions, they also uncovered several areas where additional research is needed to better understand how to most effectively improve patient experience and reduce inequities. Patient and community input will be a critical part of this longer-term research.
This fall, a researcher from the Boston University School of Social Work, Linda Sprague-Martinez, PhD, will be leading a series of one-on-one, in-depth patient interviews to better understand how preeclamptic patients experienced their care at BMC and what BMC could have done differently or better to help them throughout their pregnancy and delivery. Going forward, the Accelerator will continue working with BMC data scientists to build predictive models for both SMM and SGA.
While this work will take years, the team is energized to be taking steps now to begin eradicating long-standing inequities in maternal-infant health outcomes. They hope to rapidly be able to improve the experience and outcomes of Black patients at BMC while also sharing our findings with other health systems across the U.S.
"What empowers transformation is the voices that the Accelerator has brought in, starting with talking to our group of providers, and doulas, and MAs, and everybody on the floor," said Yarrington. "And now we're turning these questions out to our patients, because transformation needs to come from their lived experience of how the first birth went so that the second birth can be what they deserve."