Racial disparities in maternal outcomes

Racial disparities in maternal outcomes

An analysis of the impact of OB hospitalist involved care on implicit bias

Introduction

The facts are shocking: the United States has the highest maternal death rate of any developed country, and these deaths are largely preventable. For Black women, the maternal mortality rate is exceptionally high - more than double the average rate and nearly three times higher than the rate for white women.

Background

Maternal mortality in the U.S.

Many women die each year from issues related to pregnancy or delivery complications. The U.S. has the worst maternal mortality rates of any developed country, and numbers have dramatically increased in recent years. Black women continue to be affected the most.

In 2021, 1,205 women in the U.S. died from complications related to pregnancy and childbirth, compared with 861 deaths in 2020 and 754 in 2019, according to the Centers for Disease Control and Prevention (CDC). Tragically, experts estimate that about 60% of all pregnancy-related deaths are preventable.

The CDC also found that Black women were 2.6 times more likely to die from a pregnancy-related cause than white women in 2021. The maternal mortality rate for Black women was 69.9 deaths per 100,000 live births, compared to 26.6 for white women.

Understanding and addressing maternal mortality rates among Black women requires a closer look at inequalities in healthcare. It also requires a focus on unconscious bias. This report examines the clinical outcomes of patients under the care of obstetric (OB) hospitalists. The analysis spans six months, from August 2022 through February 2023, utilizing patient-reported race data.

A quarter of maternal deaths in 2020 and 2021 were COVID-19 related, according to the federal Government Accountability Office. However, overall deaths for pregnant women without COVID-19 continued to rise. The pandemic worsened risk factors associated with maternal health racial disparities, including access to care and prevalence of chronic health conditions. Research suggests that Black women receive lower quality of health care than white women, which increases the risk of pregnancy-related complications and deaths.

Across the U.S.

Black women are three times more likely to die from a pregnancy-related cause

than white women

C-section rate for Black women is higher (36%) than white women (31%)

The role of OB hospitalists in improving maternal outcomes and reducing racial disparities

There are still discrepancies in how care is delivered for pregnant women in our country. When pregnant women present emergently to the hospital and are sent to a labor and delivery unit without a physician to see them, they may receive a lower standard of care than other patients presenting to the emergency department, all of whom are seen by a physician, physician’s assistant or nurse practitioner. An OB hospitalist program with an Obstetrics Emergency Department (OBED) solves this challenge by ensuring that every expectant mother presenting in labor, or with antepartum or postpartum concerns, receives consistent and unconditional medical care by an experienced clinician at the hospital. OB hospitalists are OB/GYN clinicians who specialize in acute and emergency care of obstetrical, and in some cases, gynecologic patients in the hospital. OB hospitalist programs provide care to women with pregnancy-related

Analysis overview

Ob Hospitalist Group (OBHG), the nation’s largest and only dedicated OB hospitalist provider, has long believed every woman in America should have access to immediate, unbiased care through all stages of pregnancy. Not only are OB hospitalists well positioned to address the challenges of the nation’s maternal mortality crisis and make a difference in ending preventable maternal death in the U.S., but they can also be part of the solution to reduce racial disparities. For years, OBHG’s data has shown that its team of clinicians deliver quality outcomes that outpace national

issues until their obstetrician can arrive at the hospital or when the woman has no assigned obstetrician. With a clinician on site at all times, urgent health concerns and emergencies are quickly addressed by OB hospitalists.

To OB hospitalists, factors such as race, ethnicity, geographic region and payer status do not matter. Not only do OB hospitalists evaluate patients and handle obstetrical emergencies, but they are also very focused on best practices and safety across the entire labor delivery unit.

A recent study suggests that hospitals with 24/7 coverage of OB hospitalists have lower levels of severe maternal morbidity than those that use non-hospitalist OB/GYN providers. OB hospitalist medicine can be part of the solution to not only improve maternal outcomes, but also reduce racial disparities.

averages and goals. However, this data was not available from a race perspective.

In August 2022, OBHG launched an effort to collect patient reported racial identification as part of an initiative to evaluate racial disparities. Over a six-month period (from August 2022 through February 2023), OBHG collected data from over 31,000 OBHG clinician involved deliveries across 22 states, representing nearly 87% of OBHG’s network deliveries during the time. Additionally, data from over 319,413 patient encounters was collected.

Quality performance was evaluated for the following quality metrics:

NQF469 Elective delivery less than 39 weeks

NQF470

Vaginal delivery w/episiotomy

NQF471

AHRQ18

AHRQ19

NSTV C-sections (low-risk cesarean deliveries)

3rd/4th degree lacerations (significant lacerations after vaginal delivery) with instrumentation (forceps or vacuum)

3rd/4th degree lacerations (significant lacerations after vaginal delivery) without instrumentation

Return to the Obstetrical Emergency Department (OBED) within 48 hours for patients under 34 weeks estimated gestation (OBHG metric)

Utilizing patient-reported race data, clinical outcomes were compared to national goals and by race for each of the performance metrics.

Analysis findings

Key findings (Ob Hospitalist Group analysis, August 2022 – February 2023)

OBHG's clinical results below national average with similar outcomes, regardless of race

C-sections

C-sections, which carry increased risks for pregnant patients in their current and future pregnancies, was one focus of OBHG’s data analysis. In the U.S., the C-section rate for Black women is higher (36%) than white women (31%).

OBHG’s data showed that OBHG’s C-section outcomes were well below the national goal of 23.6% for all races.

OBHG’s C-section delivery rates were also significantly lower for all races than CDC National Vital Statistics Report Data on births, with OBHG averaging a C-section delivery rate of 19.5% compared to 26.3% reported by the CDC.

C-section delivery rates for white OBHG patients was 15% compared to the 25.2% delivery rate reported by the CDC. For Black patients, OBHG’s delivery rate was 18.2% compared to the 31.2% delivery rate reported by the CDC.

These results show that OBHG’s efforts around implementing standardized procedures and tools for C-sections is making an impact in reducing unnecessary C-sections for all races.

Lacerations and episiotomies

Lacerations and episiotomies were another focus of the analysis, as they can lead to significant long-term complications for patients. OBHG’s network performance for these metrics remained below the national goals of 5% for episiotomy, 11.7% for 3rd/4thdegree lacerations with instrumentation, and 1.7% for 3rd/4th degree lacerations without instrumentation.

Aside from slightly increased rates of episiotomies for Native Hawaiian or Other Pacific Islander, all other races remained below goal. The same is true for 3rd/4th degree lacerations with instrumentation where OBHG’s results for Native Hawaiian or Other Pacific Islander were elevated due to a low volume of patients qualifying for the metric. Finally, when evaluating the 3rd/4th degree laceration rate without instrumentation, the only racial group with a slightly elevated result was Asian.

Avoiding unnecessary care

OBHG strives to avoid providing unnecessary care to patients that can add to the overall expense of healthcare or expose patients to additional harm in the healthcare system. The results demonstrated that across all races, OBHG clinicians are not electively inducing patients under 39 weeks gestational age in line with the

national goal of 0.0%. Additionally, OBHG is meeting its internal goal of limiting the number of patients, under 34 weeks gestational age, who need to return to the OBED within 48 hours. With a 1.7% return rate, the data shows that OBHG is keeping results consistent and well below the company’s goal of 5% for all racial groups.

OBHG’s analysis of clinical outcomes by race is just one way the organization is taking action to improve maternal healthcare in our country. Other strategies OBHG is driving to support improved maternal health disparities are summarized below.

Taking action to improve maternal health disparities

Hiring practices around workplace diversity and inclusion

OBHG’s hiring process was designed to provide equal opportunities for candidates of diverse backgrounds. This process has allowed OBHG to hire and retain a diverse clinical workforce that represents the communities OBHG serves. Today, 63% of OBHG’s physicians, midwives and nurse practitioners are female and 40% identify as racial and ethnic minorities. This is even more diverse than the general population of obstetrical clinicians in the U.S. OBHG’s workforce diversity and inclusion focus is bringing benefits to patients, hospitals and throughout the organization.

Training to address bias

Unconscious or implicit bias training is one positive step organizations can take to help employees recognize and manage hidden biases. All OBHG clinical and non-clinical employees receive regular unconscious bias training to equip them with appropriate tools to act objectively without getting clouded by their implicit biases. OBHG’s Diversity and Inclusion Committee (which consists of both clinicians and support team employees), focuses on closing gaps in care caused by cultural biases and educating the workforce to foster an inclusive culture.

Continuing presence on labor and delivery

With a 24/7 onsite OBHG program, no matter the day or time, there is an experienced OBHG hospitalist on-site, ready to care for patients and handle any emergency that may come through the door. Factors such as race, ethnicity, geographic region and payer status do not matter to OBHG clinicians caring for patients. This approach enables all women to experience immediate, unbiased care through all stages of pregnancy.

Implementing evidence-based national best practices

Having the latest protocols in place is critical when it comes to providing the right care for pregnancy-related complications. Following these protocols further helps to ensure clinicians are able to be agnostic to patient race. OB hospitalists serve as the maternal safety champions of the entire labor and delivery unit, implementing standard labor and delivery protocols throughout the unit. At OBHG, we recognize that our clinicians are uniquely positioned to recommend and implement proactive strategies not just for our own hospitalist teams, but in collaboration with hospital leadership, private practice OBs, nurses, MFM specialists and others. Our teams implement and follow national protocols for all patients, leading to the best outcomes for all patients, regardless of race. We have seen many examples within our partner hospitals where patient safety has improved due to our clinicians championing standardized protocols for delivery complications such as preeclampsia and postpartum hemorrhage. We also developed a C-section reduction toolkit to combat medically unnecessary C-sections and have other toolkits underway. The value of OB hospitalists serving as maternal safety champions was highlighted in the Journal of OB/GYN Hospital Medicine

Focusing on data

OBHG utilizes a data-driven approach to uncover opportunities for new efforts that address inequity and improve maternal outcomes. For benchmarking purposes, we track the data within each of our hospital partners. When a hospital falls outside targets, we work with hospital leadership to assess the situation and develop an action plan; when a hospital demonstrates differentiated performance, our leaders identify opportunities to bring best practices to other programs across the country.

Takeaways

After six months of data collection, OBHG launched an effort to analyze clinical quality metrics by race to evaluate racial disparities of patients under the care of OB hospitalists. While there was a previous indication that OBHG clinicians were delivering on the promise of medical equity across patients’ background, there was no data to back up the assumption. To our knowledge, this is the first study or analysis to look at OB hospitalist outcomes by patient race.

We acknowledge there are some limitations to this analysis. Classification by race is dependent upon selfreporting and some patients opt to not provide this information. In addition, this analysis focused on specific quality metrics and not all potential outcomes including maternal mortality.

OB hospitalist programs, having proven their value in clinical and operational outcomes, offer greater promise than ever before. In the coming years, as the nation grapples with the ongoing maternal mortality crisis, OB hospitalists can take even more stewardship in helping bend the trajectory of the maternal mortality rate and inequities in healthcare. The results of this analysis are promising - it shows that OBHG clinicians are effectively delivering unbiased care and improving outcomes and that OB hospitalists are an important part of the solution to our nation’s maternity care crisis.

This isn’t a one-time analysis; OBHG will continue to monitor clinical outcomes by race to evaluate the impact OB hospitalists are having on key clinical indicators of maternal mortality. The hope is that the results from this analysis can aid in the approach to maternal mortality and reducing future racial disparities.

Results show that OBHG clinicians are effectively delivering unbiased care and improving outcomes.

About Ob Hospitalist Group

Ob Hospitalist Group (OBHG) is the nation’s largest and only dedicated OB hospitalist provider, focused on improving access to care and ensuring all women receive timely, unconditional obstetric care. Our team partners with hospitals across the nation to improve maternal safety and outcomes and reduce physician burnout. As part of our dedicated women’s health focus, we ensure that every pregnant woman presenting to labor and delivery with unscheduled medical needs receives timely, expert care from a skilled clinician. Our 1,500+ clinicians partner closely with local OB/GYN physicians, providing collaborative, non-competitive support. Together, we deliver great patient care and clinicians passionate about their role in caring for pregnant women. OBHG is headquartered in Greenville, SC. For more information, visit www.OBHG.com.