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1.
Artigo em Inglês | MEDLINE | ID: mdl-34806193

RESUMO

BACKGROUND: The COVID-19 pandemic is an ongoing global health threat, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Questions remain about how SARS-CoV-2 impacts pregnant individuals and their children. OBJECTIVE: To expand our understanding of the effects of SARS-CoV-2 infection during pregnancy on pregnancy outcomes, regardless of symptomatology, by using serological tests to measure IgG antibody levels. METHODS: The Generation C Study is an ongoing prospective cohort study conducted at the Mount Sinai Health System. All pregnant individuals receiving obstetrical care at the Mount Sinai Healthcare System from 20 April 2020 onwards are eligible for participation. For the current analysis, we included participants who had given birth to a liveborn singleton infant on or before 22 September 2020. For each woman, we tested the latest prenatal blood sample available to establish seropositivity using a SARS-CoV-2 serologic enzyme-linked immunosorbent assay. Additionally, RT-PCR testing was performed on a nasopharyngeal swab taken during labour. Pregnancy outcomes of interest (i.e., gestational age at delivery, preterm birth, small for gestational age, Apgar scores, maternal and neonatal intensive care unit admission, and length of neonatal hospital stay) and covariates were extracted from medical records. Excluding individuals who tested RT-PCR positive at delivery, we conducted crude and adjusted regression models to compare antibody positive with antibody negative individuals at delivery. We stratified analyses by race/ethnicity to examine potential effect modification. RESULTS: The SARS-CoV-2 seroprevalence based on IgG measurement was 16.4% (95% confidence interval 13.7, 19.3; n=116). Twelve individuals (1.7%) were SARS-CoV-2 RT-PCR positive at delivery. Seropositive individuals were generally younger, more often Black or Hispanic, and more often had public insurance and higher pre-pregnancy BMI compared with seronegative individuals. None of the examined pregnancy outcomes differed by seropositivity, overall or stratified by race/ethnicity. CONCLUSION: Seropositivity for SARS-CoV-2 without RT-PCR positivity at delivery (suggesting that infection occurred earlier during pregnancy) was not associated with selected adverse maternal or neonatal outcomes among live births in a cohort sample from New York City.

2.
Am J Obstet Gynecol ; 2021 Nov 10.
Artigo em Inglês | MEDLINE | ID: mdl-34774520

RESUMO

Profound inequities in maternal and infant outcomes based on race exist, and the maternal-fetal medicine community has an important role in eliminating these disparities. Accurately employing race and ethnicity as social constructs within research that guides clinical practice is essential to achieving health equity. We must abandon commonly propagated myths that race is a surrogate for genetics or economic status and that data are exempt from potential bias. These myths can lead to harmful misconceptions that exacerbate racial disparities in maternal and infant health outcomes. Further, these myths obscure racism as the true underlying etiology of racial disparities. Understanding that race is a social construct and utilizing an anti-racist approach to research are essential in combatting racism and eliminating unacceptable disparities in maternal and infant health. This document provides specific suggestions to approach the research process with an anti-racist framework.

3.
Arch Womens Ment Health ; 24(5): 823-830, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34427773

RESUMO

Our objective was to review the role of maternal health disparities and mental health in the maternal mortality crisis in the USA, and discuss how perinatal care quality improvement in these areas is a critical lever for reducing maternal death. This paper summarizes content from a plenary talk delivered at the 2020 Biennial Meeting of the International Marcé Society for Perinatal Mental Health, in commemoration of the Society's 40th anniversary. The talk synthesized literature on two characteristics of the maternal mortality crisis in the US: (1) wide racial and ethnic disparities in maternal mortality and severe morbidity and (2) the impact of mental health and substance use disorders on maternal death, and introduced a framework for how health care quality gaps contribute to both of these issues. The US remains an outlier among similar nations in its alarmingly high rates of maternal mortality. Achieving significant progress on this measure will require confronting longstanding racial and ethnic disparities that exist throughout the pregnancy-postpartum continuum, as well as addressing the under-reported issue of maternal self-harm. Suicide and overdose are leading but under-recognized causes of death among pregnant and postpartum women in some states. Health care delivery failures, including inadequate risk assessment, care coordination, and communication, are identified in the literature on drivers of maternal health disparities and self-harm. Many of the same steps to improve quality of perinatal care can help to reduce health disparities and address the essential role of mental health in maternal well-being.


Assuntos
Mortalidade Materna , Saúde Mental , Grupos de Populações Continentais , Grupos Étnicos , Feminino , Disparidades nos Níveis de Saúde , Humanos , Saúde Materna , Gravidez , Estados Unidos/epidemiologia
4.
Pediatrics ; 148(3)2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34429339

RESUMO

OBJECTIVES: To investigate racial and ethnic differences in unexpected, term newborn morbidity and the influence of hospital quality on disparities. METHODS: We used 2010-2014 birth certificate and discharge abstract data from 40 New York City hospitals in a retrospective cohort study of 483 834 low-risk (term, singleton, birth weight ≥2500 g, without preexisting fetal conditions) neonates. We classified morbidity according to The Joint Commission's unexpected newborn complications metric and used multivariable logistic regression to compare morbidity risk among racial and ethnic groups. We generated risk-standardized complication rates for each hospital using mixed-effects logistic regression to evaluate quality, ranked hospitals on this measure, and assessed differences in the racial and ethnic distribution of births across facilities. RESULTS: The unexpected complications rate was 48.0 per 1000 births. Adjusted for patient characteristics, morbidity risk was higher among Black and Hispanic infants compared with white infants (odds ratio: 1.5 [95% confidence interval 1.3-1.9]; odds ratio: 1.2 [95% confidence interval 1.1-1.4], respectively). Among the 40 hospitals, risk-standardized complications ranged from 25.3 to 162.8 per 1000 births. One-third of Black and Hispanic women gave birth in hospitals ranking in the highest-morbidity tertile, compared with 10% of white and Asian American women (P < .001). CONCLUSIONS: Black and Hispanic women were more likely to deliver in hospitals with high complication rates than were white or Asian American women. Findings implicate hospital quality in contributing to preventable newborn health disparities among low-risk, term births. Quality improvement targeting routine obstetric and neonatal care is critical for equity in perinatal outcomes.


Assuntos
Grupos de Populações Continentais/estatística & dados numéricos , Disparidades em Assistência à Saúde , Hospitais , Mortalidade Infantil , Doenças do Recém-Nascido/epidemiologia , Qualidade da Assistência à Saúde , Adulto , Estudos de Coortes , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Estudos Retrospectivos , Nascimento a Termo , Adulto Jovem
5.
Am J Public Health ; 111(9): 1673-1681, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34383557

RESUMO

Objectives. To better understand racial and ethnic disparities in US maternal mortality. Methods. We analyzed 2016-2017 vital statistics mortality data with cause-of-death literals (actual words written on the death certificate) added. We created a subset of confirmed maternal deaths that had pregnancy mentions in the cause-of-death literals. Primary cause of death was identified and recoded using cause-of-death literals. We examined racial and ethnic disparities both overall and by primary cause. Results. The maternal mortality rate for non-Hispanic Black women was 3.55 times that for non-Hispanic White women. Leading causes of maternal death for non-Hispanic Black women were eclampsia and preeclampsia and postpartum cardiomyopathy with rates 5 times those for non-Hispanic White women. Non-Hispanic Black maternal mortality rates from obstetric embolism and obstetric hemorrhage were 2.3 to 2.6 times those for non-Hispanic White women. Together, these 4 causes accounted for 59% of the non-Hispanic Black‒non-Hispanic White maternal mortality disparity. Conclusions. The prominence of cardiovascular-related conditions among the leading causes of confirmed maternal death, particularly for non-Hispanic Black women, necessitates increased vigilance for cardiovascular problems during the pregnant and postpartum period. Many of these deaths are preventable.


Assuntos
Grupos Étnicos/estatística & dados numéricos , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde/etnologia , Morte Materna/etiologia , Mortalidade Materna/etnologia , Adulto , Afro-Americanos/estatística & dados numéricos , Americanos Asiáticos/estatística & dados numéricos , Feminino , Hispano-Americanos/estatística & dados numéricos , Humanos , Gravidez , Fatores de Risco , Estados Unidos
6.
PLoS One ; 16(6): e0253920, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34185810

RESUMO

To better understand age-related disparities in US maternal mortality, we analyzed 2016-2017 vital statistics mortality data with cause-of-death literal text (actual words written on the death certificate) added. We created a subset of confirmed maternal deaths which had pregnancy mentions in the cause-of-death literals. Primary cause of death was identified and recoded using cause-of-death literals. Age-related disparities were examined both overall and by primary cause. Compared to women <35, the 2016-2017 US maternal mortality rate was twice as high for women aged 35-39, four times higher for women aged 40-44, and 11 times higher for women aged 45-54 years. Obstetric hemorrhage was the leading cause of death for women aged 35+ with rates 4 times higher than for women <35, followed by postpartum cardiomyopathy with a 3-fold greater risk. Obstetric embolism, eclampsia/preeclampsia, and Other complications of obstetric surgery and procedures each had a two-fold greater risk of death for women aged 35+. Together these 5 causes of death accounted for 70.9% of the elevated maternal mortality risk for women aged 35+. The excess maternal mortality risk for women aged 35+ was focused among a few causes of death and much of this excess mortality is preventable. Early detection and treatment, as well as continued care during the postpartum year is critical to preventing these deaths. The Alliance for Innovation on Maternal Health has promulgated patient safety bundles with specific interventions that health care systems can adopt in an effort to prevent these deaths.


Assuntos
Eclampsia/mortalidade , Morte Materna , Mortalidade Materna , Complicações na Gravidez/mortalidade , Adulto , Causas de Morte , Eclampsia/patologia , Feminino , Humanos , Complicações do Trabalho de Parto/mortalidade , Procedimentos Cirúrgicos Obstétricos/efeitos adversos , Período Pós-Parto , Gravidez , Complicações na Gravidez/patologia , Estados Unidos/epidemiologia
7.
Obstet Gynecol ; 137(5): 864-872, 2021 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-33831920

RESUMO

OBJECTIVE: To evaluate the role of prepregnancy obesity as a mediator in the association between race-ethnicity and severe maternal morbidity. METHODS: We conducted an analysis on a population-based retrospective cohort study using 2010-2014 birth records linked with hospital discharge data in New York City. A multivariable logistic regression mediation model on a subgroup of the sample consisting of normal-weight and obese women (n=409,021) calculated the mediation effect of obesity in the association between maternal race-ethnicity and severe maternal morbidity, and the residual effect not mediated by obesity. A sensitivity analysis was conducted excluding the severe maternal morbidity cases due to blood transfusion. RESULTS: Among 591,455 live births, we identified 15,158 cases of severe maternal morbidity (256.3/10,000 deliveries). The severe maternal morbidity rate among obese women was higher than that of normal-weight women (342 vs 216/10,000 deliveries). Black women had a severe maternal morbidity rate nearly three times higher than White women (420 vs 146/10,000 deliveries) and the severe maternal morbidity rate among Latinas was nearly twice that of White women (285/10,000 deliveries). Among women with normal or obese body mass index (BMI) only (n=409,021), Black race was strongly associated with severe maternal morbidity (adjusted odds ratio [aOR] 3.02, 95% CI 2.88-3.17) but the obesity-mediated effect represented only 3.2% of the total association (aOR 1.03, 95% CI 1.02-1.05). Latina ethnicity was also associated with severe maternal morbidity (aOR 2.01, 95% CI 1.90-2.12) and the obesity-mediated effect was similarly small: 3.4% of the total association (aOR 1.02, 95% CI 1.01-1.03). In a sensitivity analysis excluding blood transfusion, severe maternal morbidity cases found a higher mediation effect of obesity in the association with Black race and Latina ethnicity (15.3% and 15.2% of the total association, respectively). CONCLUSION: Our findings indicate that prepregnancy obesity, a modifiable factor, is a limited driver of racial-ethnic disparities in overall severe maternal morbidity.


Assuntos
Obesidade , Complicações na Gravidez/epidemiologia , Adulto , Estudos de Coortes , Registros Eletrônicos de Saúde , Grupos Étnicos , Feminino , Disparidades em Assistência à Saúde , Humanos , Serviços de Saúde Materna , Cidade de Nova Iorque/epidemiologia , Gravidez , Complicações na Gravidez/etnologia , Cuidado Pré-Natal , Estudos Retrospectivos , Adulto Jovem
8.
Matern Child Health J ; 25(6): 860-869, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33909205

RESUMO

OBJECTIVE: To examine the impact of the COVID-19 pandemic on birth satisfaction and perceived health care discrimination during childbirth, and in turn, the influence of these birth experiences on postpartum health. STUDY DESIGN: We conducted a cross-sectional, bilingual web survey of 237 women who gave birth at two hospitals in New York City and assessed patient-reported experience and outcomes following the first wave of SARS-CoV-2 infections in the New York region. We ascertained SARS-CoV-2 status at delivery from the electronic medical record using participant-reported name and date of birth. We compared birth experience during the COVID-19 pandemic (March 15, 2020-May 11, 2020) to a pre-pandemic response period (January 1, 2020-March 14, 2020). We estimated risk ratios for associations between birth experience and anxiety, depressive symptoms, stress, birth-related PTSD, emergency department visits, timely postpartum visit, and exclusive breastfeeding. Multivariable models adjusted for age, race-ethnicity, insurance, education, parity, BMI, previous experience of maltreatment/abuse and cesarean delivery. RESULTS: Women who gave birth during the peak of the pandemic response, and those that were SARS-CoV-2 positive, Black, and Latina, had lower birth satisfaction and higher perceived health care discrimination. Women with lower birth satisfaction were more likely to report higher postpartum anxiety, stress, depressive symptoms, and lower exclusive breastfeeding. Experiencing one or more incident of health care discrimination was associated with higher levels of postpartum stress and birth-related PTSD. CONCLUSION: Hospitals and policy-makers should institute measures to safeguard against a negative birth experience during the ongoing COVID-19 pandemic, particularly among birthing people of color.


Assuntos
Ansiedade/psicologia , COVID-19 , Atenção à Saúde/organização & administração , Parto/psicologia , Satisfação Pessoal , Adulto , Estudos Transversais , Feminino , Nível de Saúde , Humanos , Pandemias , Período Pós-Parto , Gravidez , SARS-CoV-2 , Adulto Jovem
9.
Semin Perinatol ; 45(4): 151410, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33865629

RESUMO

Differences in the quality of delivery hospital care contribute to persistent, intertwined racial and ethnic disparities in both maternal and infant health. Despite the shared causal pathways and overlapping burden of maternal and infant health disparities, little research on perinatal quality of care has addressed obstetric and neonatal care jointly to improve outcomes and reduce health inequities for the maternal-infant dyad. In this paper, we review the role of hospital quality in shaping perinatal health outcomes, and investigate how a framework that considers the mother-infant dyad can enhance our understanding of the full burden of obstetric and neonatal disparities on health and society. We conclude with a discussion of how integrating a maternal-infant dyad lens into research and clinical intervention to improve quality of care can move the needle on disparity reduction for both women and infants around the time of birth and throughout the life course.


Assuntos
Equidade em Saúde , Grupos Étnicos , Feminino , Humanos , Lactente , Saúde do Lactente , Recém-Nascido , Mães , Parto , Gravidez
10.
J Pediatr ; 235: 116-123, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33794221

RESUMO

OBJECTIVE: To assess the influence of racial and economic residential segregation of home or hospital neighborhood on very preterm birth morbidity and mortality in neonates born very preterm. STUDY DESIGN: We constructed a retrospective cohort of n = 6461 infants born <32 weeks using 2010-2014 New York City vital statistics-hospital data. We calculated racial and economic Index of Concentration at the Extremes for home and hospital neighborhoods. Neonatal mortality and morbidity was defined as death and/or severe neonatal morbidity. We estimated relative risks for Index of Concentration at the Extremes measures and neonatal mortality and morbidity using log binomial regression and the risk-adjusted contribution of delivery hospital using Fairlie decomposition. RESULTS: Infants whose mothers live in neighborhoods with the greatest relative concentration of Black residents had a 1.6 times greater risk of neonatal mortality and morbidity than those with the greatest relative concentration of White residents (95% CI 1.2-2.1). Delivery hospital explained more than one-half of neighborhood differences. Infants with both home and hospital in high-concentration Black neighborhoods had a 38% adjusted risk of neonatal mortality and morbidity compared with 25% of those with both home and hospital high-concentration White neighborhoods (P = .045). CONCLUSIONS: Structural racism influences very preterm birth neonatal mortality and morbidity through both the home and hospital neighborhood. Quality improvement interventions should incorporate a framework that includes neighborhood context.


Assuntos
Afro-Americanos/estatística & dados numéricos , Mortalidade Infantil , Recém-Nascido Prematuro , Nascimento Prematuro/epidemiologia , Características de Residência , Adulto , Estudos de Coortes , Feminino , Hospitais/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Doenças do Recém-Nascido/epidemiologia , Cidade de Nova Iorque/epidemiologia , Gravidez , Estudos Retrospectivos
11.
Epilepsia ; 62(5): 1148-1157, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33689181

RESUMO

OBJECTIVE: To assess whether epilepsy is associated with increased odds of 30-day readmission due to psychiatric illness during the postpartum period. METHODS: The 2014 Nationwide Readmissions Database and the International Classification of Disease, Ninth Revision, Clinical Modification codes were used to identify postpartum women up to 50 years old in the United States, including the subgroup with epilepsy. The primary outcome was 30-day readmission and was categorized as (1) readmission due to psychiatric illness, (2) readmission due to all other causes, or (3) no readmission. Secondary outcome was diagnosis at readmission. The association of the primary outcome and presence of epilepsy was examined using multinomial logistic regression. RESULTS: Of 1 558 875 women with admissions for delivery identified, 6745 (.45%) had epilepsy. Thirteen of every 10 000 women had 30-day psychiatric readmissions in the epilepsy group compared to one of every 10 000 in the no-epilepsy group (p < .0001). Of every 10 000 women with epilepsy, 256 had 30-day readmissions due to other causes compared to 115 of every 10 000 women in the no-epilepsy group (p < .0001). The odds ratio for readmission due to psychiatric illness was 10.13 (95% confidence interval = 5.48-18.72) in those with epilepsy compared to those without. Top psychiatric causes for 30-day readmissions among women with epilepsy were mood disorders, schizophrenia and other psychotic disorders, and substance-related disorders. SIGNIFICANCE: This large-scale study demonstrated that postpartum women with epilepsy have higher odds of readmission due to a psychiatric illness compared to women without epilepsy. Postpartum treatment strategies and interventions to prevent psychiatric readmissions are necessary in this vulnerable population.


Assuntos
Epilepsia , Transtornos Mentais/epidemiologia , Complicações na Gravidez , Transtornos Puerperais/epidemiologia , Adulto , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Gravidez , Estudos Retrospectivos , Estados Unidos/epidemiologia
12.
JAMA Netw Open ; 4(3): e211816, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33729505

RESUMO

Importance: The coronavirus disease 2019 (COVID-19) pandemic may exacerbate existing racial/ethnic inequities in preterm birth. Objective: To assess whether racial/ethnic disparities in very preterm birth (VPTB) and preterm birth (PTB) increased during the first wave of the COVID-19 pandemic in New York City. Design, Setting, and Participants: This cross-sectional study included 8026 Black, Latina, and White women who gave birth during the study period. A difference-in-differences (DID) analysis of Black vs White disparities in VPTB or PTB in a pandemic cohort was compared with a prepandemic cohort by using electronic medical records obtained from 2 hospitals in New York City. Exposures: Women who delivered from March 28 to July 31, 2020, were considered the pandemic cohort, and women who delivered from March 28 to July 31, 2019, were considered the prepandemic cohort. Reverse transcription-polymerase chain reaction tests for the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were performed using samples obtained via nasopharyngeal swab at the time of admission. Main Outcomes and Measures: Clinical estimates of gestational age were used to calculate VPTB (<32 weeks) and PTB (<37 weeks). Log binomial regression was performed to estimate Black vs White risk differences, pandemic cohort vs prepandemic cohort risk difference, and an interaction term representing the DID estimator. Covariate-adjusted models included age, insurance, prepregnancy body mass index, and parity. Results: Of 3834 women in the pandemic cohort, 492 (12.8%) self-identified as Black, 678 (17.7%) as Latina, 2012 (52.5%) as White, 408 (10.6%) as Asian, and 244 (6.4%) as other or unspecified race/ethnicity, with approximately half the women 25 to 34 years of age. The prepandemic cohort comprised 4192 women with similar sociodemographic characteristics. In the prepandemic cohort, VPTB risk was 4.4% (20 of 451) and PTB risk was 14.4% (65 of 451) among Black infants compared with 0.8% (17 of 2188) VPTB risk and 7.1% (156 of 2188) PTB risk among White infants. In the pandemic cohort, VPTB risk was 4.3% (21 of 491) and PTB risk was 13.2% (65 of 491) among Black infants compared with 0.5% (10 of 1994) VPTB risk and 7.0% (240 of 1994) PTB risk among White infants. The DID estimators indicated that no increase in Black vs White disparities were found (DID estimator for VPTB, 0.1 additional cases per 100 [95% CI, -2.5 to 2.8]; DID estimator for PTB, 1.1 fewer case per 100 [95% CI, -5.8 to 3.6]). The results were comparable in covariate-adjusted models when limiting the population to women who tested negative for SARS-CoV-2. No change was detected in Latina vs White PTB disparities during the pandemic. Conclusions and Relevance: In this cross-sectional study of women who gave birth in New York City during the COVID-19 pandemic, no evidence was found for increased racial/ethnic disparities in PTB, among women who tested positive or tested negative for SARS-CoV-2.


Assuntos
Afro-Americanos , COVID-19 , Idade Gestacional , Disparidades nos Níveis de Saúde , Hispano-Americanos , Pandemias , Nascimento Prematuro/etnologia , Adulto , Estudos de Coortes , Estudos Transversais , Grupo com Ancestrais do Continente Europeu , Feminino , Humanos , Lactente , Recém-Nascido , Cidade de Nova Iorque/epidemiologia , Gravidez , Nascimento Prematuro/virologia , SARS-CoV-2 , Adulto Jovem
13.
Womens Health Issues ; 31(1): 75-81, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33069559

RESUMO

INTRODUCTION: Racial and ethnic disparities in rates of maternal morbidity and mortality in the United States are striking and persistent. Despite evidence that variation in the quality of care contributes substantially to these disparities, we do not sufficiently understand how experiences of perinatal care differ by race and ethnicity among women with severe maternal morbidity. METHODS: We conducted focus groups with women who experienced a severe maternal morbidity event in a New York City hospital during their most recent pregnancy (n = 20). We organized three focus groups by self-identified race/ethnicity ([1] Black, [2] Latina, and [3] White or Asian) to detect any within- and between-group differences. Discussions were audiotaped and transcribed. The research team coded the transcripts and used content analysis to identify key themes and to compare findings across racial and ethnic groups. RESULTS: Participants reported distressing experiences and lasting emotional consequences after having a severe childbirth complication. Many women appreciated the life-saving care they received. However, poor continuity of care, communication gaps, and a perceived lack of attentiveness to participants' physical and emotional needs led to substantial concern and disappointment in care. Black and Latina women in particular emphasized these themes. CONCLUSIONS: This study highlights missed opportunities for improved clinician communication and continuity of care to address emotional trauma when severe obstetric complications occur, particularly for Black and Latina women. Enhancing communication to ensure that women feel heard and informed throughout the birth process and addressing implicit bias, as a part of the more systemic issue of institutionalized racism, could both decrease disparities in obstetric care quality and improve the patient experience for women of all races and ethnicities.


Assuntos
Grupos Étnicos , Período Periparto , Afro-Americanos , Grupo com Ancestrais do Continente Europeu , Feminino , Humanos , Cidade de Nova Iorque , Gravidez , Estados Unidos
14.
J Perinatol ; 41(3): 413-421, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-32669647

RESUMO

OBJECTIVE: To learn how diverse mothers whose babies required a neonatal intensive care unit (NICU) stay evaluate their obstetric and neonatal care. STUDY DESIGN: We conducted three focus groups stratified by race/ethnicity (Black, Latina, White, and Asian women, n = 20) who delivered infants at <32 weeks gestation or <1500 g with a NICU stay. We asked women to assess perinatal care and applied classic qualitative analysis techniques to identify themes and make comparisons across groups. RESULTS: Predominant themes were similar across groups, including thoroughness and consistency of clinician communication, provider attentiveness, and barriers to closeness with infants. Care experiences were largely positive, but some suggested poorer communication and responsiveness toward Black and Latina mothers. CONCLUSION: Feeling consulted and included in infant care is critical for mothers of high-risk neonates. Further in-depth research is needed to remediate differences in hospital culture and quality that contribute to disparities in neonatal care and outcomes.


Assuntos
Unidades de Terapia Intensiva Neonatal , Assistência Perinatal , Criança , Feminino , Idade Gestacional , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Mães , Gravidez
15.
Health Aff (Millwood) ; 39(11): 1909-1916, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33136505

RESUMO

Recent literature has focused on the impact of the differential adoption by states of the Affordable Care Act's Medicaid expansion. However, additional Medicaid policy dimensions exist where state-level trends in coverage have varied, including eligibility, benefits, and administrative burden, both before and after implementation of the Affordable Care Act.


Assuntos
Medicaid , Patient Protection and Affordable Care Act , Definição da Elegibilidade , Acesso aos Serviços de Saúde , Humanos , Cobertura do Seguro , Estados Unidos
16.
Ethn Dis ; 30(4): 533-542, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32989353

RESUMO

Background: Black and Latina women in New York City are twice as likely to experience a potentially life-threatening morbidity during childbirth than White women. Health care quality is thought to play a role in this stark disparity, and patient-provider communication is one aspect of health care quality targeted for improvement. Perceived health care discrimination may influence patient-provider communication but has not been adequately explored during the birth hospitalization. Purpose: Our objective was to investigate the impact of perceived racial-ethnic discrimination on patient-provider communication among Black and Latina women giving birth in a hospital setting. Methods: We conducted four focus groups of Black and Latina women (n=27) who gave birth in the past year at a large hospital in New York City. Moderators of concordant race/ethnicity asked a series of questions on the women's experiences and interactions with health care providers during their birth hospitalizations. One group was conducted in Spanish. We used an integrative analytic approach. We used the behavioral model for vulnerable populations adapted for critical race theory as a starting conceptual model. Two analysts deductively coded transcripts for emergent themes, using constant comparison method to reconcile and refine code structure. Codes were categorized into themes and assigned to conceptual model categories. Results: Predisposing patient factors in our conceptual model were intersectional identities (eg, immigrant/Latina or Black/Medicaid recipient), race consciousness ("…as a woman of color, if I am not assertive, if I am not willing to ask, then they will not make an effort to answer"), and socially assigned race (eg, "what you look like, how you talk"). We classified themes of differential treatment as impeding factors, which included factors overlooked in previous research, such as perceived differential treatment due to the relationship with the infant's father and room assignment. Themes for differential treatment co-occurred with negative provider communication attributes (eg, impersonal, judgmental) or experience (eg, not listened to, given low priority, preferences not respected). Conclusions: Perceived racial-ethnic discrimination during childbirth influences patient-provider communication and is an important and potentially modifiable aspect of the patient experience. Interventions to reduce obstetric health care disparities should address perceived discrimination, both from the provider and patient perspectives.


Assuntos
Comunicação , Grupos Étnicos/psicologia , Relações Médico-Paciente , Racismo , Adulto , Afro-Americanos/psicologia , Grupo com Ancestrais do Continente Europeu/psicologia , Feminino , Grupos Focais , Disparidades em Assistência à Saúde , Hispano-Americanos/psicologia , Hospitalização , Humanos , Cidade de Nova Iorque , Parto , Percepção , Gravidez , Qualidade da Assistência à Saúde , Adulto Jovem
17.
J Am Coll Cardiol ; 76(1): 57-67, 2020 07 07.
Artigo em Inglês | MEDLINE | ID: mdl-32616164

RESUMO

BACKGROUND: Women who deliver pre-term have been reported to have increased future risks of cardiometabolic disorders. However, their long-term risks of ischemic heart disease (IHD) and whether such risks are due to shared familial factors are unclear. A better understanding of these risks may help improve long-term clinical follow-up and interventions to prevent IHD in women. OBJECTIVES: The purpose of this study was to determine the long-term risks of IHD in women by pregnancy duration. METHODS: A national cohort study was conducted of all 2,189,190 women with a singleton delivery in Sweden from 1973 to 2015, who were followed up for IHD through the end of 2015. Cox regression was used to compute adjusted hazard ratios (aHRs) for IHD associated with pregnancy duration, and cosibling analyses assessed the influence of shared familial (genetic and/or environmental) factors. RESULTS: In 47.5 million person-years of follow-up, 49,955 (2.3%) women were diagnosed with IHD. In the 10 years following delivery, the aHR for IHD associated with pre-term delivery (<37 weeks) was 2.47 (95% confidence interval [CI]: 2.16 to 2.82), and further stratified was 4.04 (95% CI: 2.69 to 6.08) for extremely pre-term (22 to 27 weeks), 2.62 (95% CI: 2.09 to 3.29) for very pre-term (28 to 33 weeks), 2.30 (95% CI: 1.97 to 2.70) for late pre-term (34 to 36 weeks), and 1.47 (95% CI: 1.30 to 1.65) for early-term (37 to 38 weeks), compared with full-term (39 to 41 weeks). These risks declined but remained significantly elevated after additional follow-up (pre-term vs. full-term, 10 to 19 years: aHR: 1.86; 95% CI: 1.73 to 1.99; 20 to 29 years: aHR: 1.52; 95% CI: 1.45 to 1.59; 30 to 43 years: aHR: 1.38; 95% CI: 1.32 to 1.45). These findings did not appear attributable to shared genetic or environmental factors within families. Additional pre-term deliveries were associated with further increases in risk. CONCLUSIONS: In this large national cohort, pre-term delivery was a strong independent risk factor for IHD. This association waned over time but remained substantially elevated up to 40 years later. Pre-term delivery should be recognized as a risk factor for IHD in women across the life course.


Assuntos
Isquemia Miocárdica/epidemiologia , Nascimento Prematuro/epidemiologia , Sistema de Registros , Medição de Risco , Adulto , Feminino , Seguimentos , Humanos , Recém-Nascido , Masculino , Isquemia Miocárdica/etiologia , Gravidez , Estudos Retrospectivos , Fatores de Risco , Suécia/epidemiologia
18.
Am J Public Health ; 110(S2): S215-S218, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32663077

RESUMO

A health care system and a Medicaid payer partnered to develop an educational intervention and payment redesign program to improve timely postpartum visits for low-income, high-risk mothers in New York City between April 2015 and October 2016. The timely postpartum visit rate was higher for 363 mothers continuously enrolled in the program than for a control group matched by propensity score (67% [243/363] and 56% [407/726], respectively; P < .001). An innovative partnership between a health care system and Medicaid payer improved access to health care services and community resources for high-risk mothers.


Assuntos
Custo Compartilhado de Seguro/métodos , Medicaid/economia , Cuidado Pós-Natal/estatística & dados numéricos , Adulto , Feminino , Humanos , Programas de Assistência Gerenciada , Motivação , Cidade de Nova Iorque , Educação de Pacientes como Assunto/métodos , Cuidado Pós-Natal/economia , Pobreza , Gravidez , Gravidez de Alto Risco , Centros de Atenção Terciária , Estados Unidos
19.
Health Aff (Millwood) ; 39(5): 768-776, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32364858

RESUMO

Recent national and state legislation has called attention to stark racial/ethnic disparities in maternal mortality and severe maternal morbidity (SMM), the latter of which is defined as having a life-threatening condition or life-saving procedure during childbirth. Using linked New York City birth and hospitalization data for 2012-14, we examined whether racial and economic spatial polarization is associated with SMM rates, and whether the delivery hospital partially explains the association. Women in ZIP codes with the highest concentration of poor blacks relative to wealthy whites experienced 4.0 cases of SMM per 100 deliveries, compared with 1.7 cases per 100 deliveries among women in the neighborhoods with the lowest concentration (risk difference = 2.4 cases per 100). Thirty-five percent of this difference was attributable to the delivery hospital. Women in highly polarized neighborhoods were most likely to deliver in hospitals located in similarly polarized neighborhoods. Housing policy that targets racial and economic spatial polarization may address a root cause of SMM, while hospital quality improvement may mitigate the impact of such polarization.


Assuntos
Afro-Americanos , Grupo com Ancestrais do Continente Europeu , Grupos de Populações Continentais , Feminino , Hospitais , Humanos , Morbidade , Cidade de Nova Iorque/epidemiologia , Gravidez
20.
Matern Child Health J ; 24(6): 687-693, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32303940

RESUMO

OBJECTIVE: To determine whether delivery hospitals that perform poorly for women also perform poorly for high-risk infants and to what extent Black and Hispanic women receive care at hospitals that perform poorly for both women and infants. METHODS: We examined the correlation between hospital rankings for severe maternal morbidity and very preterm morbidity and mortality in New York City Hospitals using linked birth certificate and state discharge data for 2010-2014. We used mixed-effects logistic regression with a random hospital-specific intercept to generate risk standardized severe maternal morbidity rates and very preterm birth neonatal morbidity and mortality rates for each hospital. We ranked hospitals separately by these risk-standardized rates. We used k-means cluster analysis to categorize hospitals based on their performance on both metrics and risk-adjusted multinomial logistic regression to estimate adjusted probabilities of delivering in each hospital-quality cluster by race/ethnicity. RESULTS: Hospital rankings for severe maternal morbidity and very preterm neonatal morbidity-mortality were moderately correlated (r = .32; p = .05). A 5-cluster solution best fit the data and yielded the categories for hospital performance for women and infants: excellent, good, fair, fair to poor, poor. Black and Hispanic versus White women were less likely to deliver in an excellent quality cluster (adjusted percent of 11%, 18% vs 28%, respectively, p < .001) and more likely to deliver in a poor quality cluster (adjusted percent of 28%, 20%, vs. 4%, respectively, p < .001). CONCLUSIONS FOR PRACTISE: Hospital performance for maternal and high-risk infant outcomes is only moderately correlated but Black and Hispanic women deliver at hospitals with worse outcomes for both women and very preterm infants.


Assuntos
Disparidades em Assistência à Saúde/estatística & dados numéricos , Mortalidade Infantil , Saúde Materna/estatística & dados numéricos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Adulto , Afro-Americanos/estatística & dados numéricos , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Hispano-Americanos/estatística & dados numéricos , Hospitais , Humanos , Lactente , Recém-Nascido , Recém-Nascido Prematuro , Doenças do Prematuro/epidemiologia , Masculino , Pessoa de Meia-Idade , Morbidade , Cidade de Nova Iorque/epidemiologia , Gravidez , Adulto Jovem
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