Addressing Racial Disparities in Maternal Health: The Case for an Equity Birth Plan

Birth equity can be defined as “The assurance of the conditions of optimal births for all people with a willingness to address racial and social inequities in a sustained effort.” (Birth Equity |California Maternal Quality Care Collaborative, n.d.). Complex explanations exist for adverse maternal outcomes, but unequal health care, socioeconomic and racial inequalities pose risks to women and their babies (“Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” 2003). The data is clear: Maternal death rates have increased and are 3 to 4 times higher for black women than white women (Zaharatos et al., 2018). These disparities exist even for black women of higher socioeconomic status where issue of access and resources would presumably be eliminated. Current data are inadequate in addressing issues of access, fragmentation of care, systemic racism, and the differential treatment of women of color. Birth plans were developed in the 1980s and were aimed at addressing patient autonomy in male dominated health care systems; birth plans provided a vehicle for patients to communicate their birthing preferences (Penny Simkin, 2007) (Kaufman, 2007). A recent Google search for “birth plan template” resulted in over 9 million results- most of which were simply provided checklists. Most identified plans fail to explain birthing options and fail to address individualized risks

Factors associated with attendance at the postpartum blood pressure visit in pregnancies complicated by hypertension.

OBJECTIVES: Women with hypertensive disorders of pregnancy should have a blood pressure evaluation no later than 7-10 days after delivery. The objective of this study was to identify the factors associated with patient attendance at the postpartum blood pressure follow-up visit. STUDY DESIGN: This was a retrospective cohort study of postpartum women who had a hypertensive disorder of pregnancy. Postpartum follow-up rates were recorded, and characteristics of women who attended a postpartum visit for blood pressure evaluation were compared to women who did not return for the visit. Multiple logistic regression was performed. MAIN OUTCOME MEASURES: Characteristics of women who returned for a blood pressure visit. RESULTS: There were 378 women who met inclusion criteria; 193(51.1%) attended the blood pressure visit. Women who returned were older and more likely to have preeclampsia, severe features, magnesium sulfate use, or severe hypertension during hospitalization. They were less likely to have gestational hypertension. Adjusted analysis demonstrated that black/non-Hispanic women (OR 0.53, 95% CI 0.34-0.83), the presence of any preeclampsia diagnosis (OR 2.19, 95% CI 1.03-4.81), and whether the woman underwent a cesarean delivery (OR 3.06, 95% CI 1.85-5.14) remained significant factors in predicting adherence. CONCLUSIONS: Women who returned for a blood pressure visit were more likely to have had significant hypertensive disease or a cesarean delivery. Non-Hispanic black women had the lowest rate of follow-up. Given black women have the highest rates of maternal morbidity and mortality nationwide, effective interventions to increase follow-up for them are needed

Risk Factors for Hepatitis C Infection Among Sexually Transmitted Disease-Infected, Inner City Obstetric Patients

Objective: To test the hypothesis that our inner city obstetric patients who have been infected with sexually transmitted diseases (STDs) will have a higher prevalence of hepatitis C virus infection than the general population and to identify specific risk factors and high-risk groups. Methods: All patients in our prenatal clinic (July 1997–April 1999) who tested positive for one or more STDs were asked to return for hepatitis C antibody testing. Medical charts of all patients who returned for hepatitis C testing were reviewed. Results: A total of 106 patients with STDs were tested for hepatitis C. Positive screening tests for anti-hepatitis C antibody were found in 6.6% (7/106) of the patients (95% CI = 2.7–13.1%). This frequency is significantly higher than the hepatitis C prevalence (1.8%) in the general United States population (p = 0.006). Multiple logistic regression analysis confirmed only older age (p = 0.016) and positive HIV status (p = 0.023) to be significant predictors of hepatitis C infection. Conclusions: Inner city STD-infected obstetric patients are at high risk for hepatitis C infection compared with the general population. Increasing age and HIV-positive status are risk factors which are significantly associated with hepatitis C infection

Maternal morbidity after early preterm delivery (23-28 weeks).

BACKGROUND: Previous research has focused mainly on neonatal outcomes associated with preterm and periviable delivery, but maternal outcomes with preterm delivery are less well described. OBJECTIVE: This study aimed to determine if early preterm delivery results in an increase in maternal morbidity. STUDY DESIGN: This is a retrospective cohort study conducted at a tertiary care center over a 5-year time period. Subjects were women identified by review of neonatal intensive care unit admission logs. Women were included if they delivered between 23 0/7 and 28 6/7 weeks\u27 gestation and their neonate was admitted to the neonatal intensive care unit. The prevalence of maternal morbidities was assessed, including blood transfusion, maternal infection, placental abruption, postpartum depression or positive depression screen, hemorrhage, and prolonged maternal postpartum hospitalization. A composite outcome comprising blood transfusion, maternal infectious morbidity, placental abruption, and postpartum depression was developed. Outcomes for women who delivered between 23 0/7 and 25 6/7 weeks\u27 gestation (early group) and 26 0/7 and 28 6/7 weeks\u27 gestation (late group) were compared. Multivariate logistic regression analysis was performed to evaluate contributors to the composite morbidity, controlling for confounding. RESULTS: A total of 82 women met the inclusion criteria: 38 in the early group and 44 in the late group. Maternal demographics were similar between the groups. The early group was significantly more likely to experience composite maternal morbidity (60.5% vs 27.3%; P=.004) and infection (42.1% vs 13.6%; P=.006). Regression analysis determined that delivery at a later gestational age was associated with lower rates of composite morbidity (odds ratio, 0.6; 95% confidence interval, 0.41-0.83). CONCLUSION: In this study, data suggest that maternal morbidity is higher with delivery at periviable gestational ages. Composite morbidity and maternal infection were more frequent in women who delivered at less than 26 weeks\u27 gestation. The management of women at risk for delivery at early gestational ages should include a discussion of increased maternal complications

Salmonella enterica Serotype Typhi Bacteremia Complicating Pregnancy in the Third Trimester

Background. Salmonella enterica serotype Typhi (S. Typhi) is an anaerobic gram-negative enteric rod that causes infection when contaminated food or water is ingested and may cause illness in pregnancy. Case. This is a patient who presented at 31 weeks’ gestation with abdominal pain and fever and was diagnosed with S. Typhi bacteremia. Conclusion. S. Typhi should be considered in febrile patients with recent travel presenting with abdominal discomfort with or without elevated liver enzymes

Maternal antepartum antibiotic administration and patterns of bacterial resistance in early preterm neonates.

OBJECTIVE: The objective of this study was to determine the relationship between maternal antepartum antibiotic administration and antibiotic resistance patterns in preterm neonates admitted to the neonatal intensive care unit (NICU). METHODS: This was a retrospective cohort study of women and their preterm neonates delivered at a single tertiary care center over a 5-year period. Women and neonates were included if they delivered between 23 weeks 0 days and 28 weeks 6 days of gestation and neonates were admitted to the NICU. Subjects were excluded if there was incomplete antibiotic administration data or incomplete laboratory or bacterial culture data for either mothers or neonates. Data collected from maternal and neonatal charts included the type, duration, and total number of antibiotics administered to subjects, neonatal culture results within the first 7 days of life, and bacterial antibiotic resistance information. Women with neonates that cultured positive for bacteria demonstrating antibiotic resistance were compared to those whose neonates did not have antibiotic-resistant bacteria. RESULTS: 79 women with 90 neonates met inclusion criteria. Of the 79 women, 71 (89.9%) received at least 1 antibiotic antepartum. 14 neonatal bacterial isolates were resistant to at least 1 antibiotic. Antibiotic-resistant bacteria were present in 11 neonates; 3 neonates had more than 1 resistant bacteria cultured. The most common resistant bacteria cultured were Coagulase-negative CONCLUSIONS: Although preterm neonates are often treated for presumed sepsis, they infrequently have positive bacterial cultures. In this study, those that had positive bacterial cultures for resistant bacteria were born at earlier gestational ages and had lower birth weights. These bacteria cultured in neonates are likely to be resistant to antibiotics received by mothers in the antepartum period. Careful selection of maternal and neonatal antibiotics in the preterm setting with consideration for local antibiotic resistance patterns is suggested