Maternal Disparities - Maternal Health Resources

Objectives: The purpose of this study was to determine whether women's sociodemographic characteristics are independently associated with cesarean delivery. Methods: A retrospective review was conducted of hospital discharge data for singleton first births in California in 1991. Results: After insurance and personal, community, medical, and hospital characteristics had been controlled, Blacks were 24% more likely to undergo cesarean delivery than Whites; only among low-birthweight and county hospital births were Blacks not at a significantly elevated risk. Among women who resided in substantially non-English-speaking communities, who delivered high-birthweight babies, or who gave birth at for-profit hospitals, cesarean delivery appeared to be more likely among non-Whites and ws over 40% more likely among Blacks than among Whites. Conclusions: The findings cannot establish causation, but the significant racial/ethnic disparities in delivery mode, despite adjustment for social, economic, medical, and hospital factors, suggest inappropriate influences on clinical decision making that would not be addressed by changes in reimbursement. If practice variations among providers are involved, de facto racial differences in access to optimal care may be indicated. The role of provider and patient attitudes and expectations in the observed racial/ethnic differentials should also be explored.

Racial disparities in health, including elevated rates of hypertension (HT) among Blacks, are widely recognized and a matter of serious concern. Researchers have hypothesized that social stress, and in particular exposure to racism, may account for some of the between-group differences in the prevalence of HT and a portion of the within-group variations in risk for HT. However, there have been surprisingly fewempirical studies of the relationship between perceived racism and blood pressure (BP) or cardiovascular reactivity (CVR), a possible marker of mechanisms culminating in cardiovascular disease. This article reviews published literature investigating the relationship of perceived racism toHT-related variables, including self-reported history of HT,BPlevel, orCVR.Strengthsandweaknesses of the existing research are discussed to permit the identification of research areas that may elucidate the biopsychosocial mechanisms potentially linking racism toHT.Wehopeto encourage investigators to invest in researchonthe health effects of racismbecauseasoundanddetailed knowledge base in this area is necessary to address racial disparities in health.

OBJECTIVE: The purpose of this study was to examine racial disparities and the "Hispanic paradox" in pregnancy outcomes at a tertiary-care medical center.
STUDY DESIGN: A cross-sectional study of pregnancy events was performed with information from the Duke University birth database. The latter includes data on birth outcomes, cost, and health services factors. The final sample included 10,755 women with Medicaid insurance, who gave birth during calendar years 1994-2004. Pregnancy comorbidities and outcome measures were identified by International Classification of Diseases, 9th revision, and Current Procedural Terminology (CPT) codes. Univariate and multivariate analyses were performed to compare racial/ethnic groups.
RESULTS: African-American women were younger and more likely to be employed, to have a medical comorbidity, to remain in the hospital for >4 days, and to have hospital charges of >$7500. African-American women had higher rates of preterm birth, small-for-gestational-age infants, preeclampsia, and stillbirths. There were no differences by race for gestational diabetes mellitus. With the use of white women as the reference group, Hispanic women had lower odds for preterm birth (odds ratio, 0.66; 95% CI, 0.54-0.80), and African-American women had greater odds for preeclampsia (odds ratio, 1.30; 95% CI, 1.07-1.58) and small-for-gestational-age infants (odds ratio, 1.74; 95% CI, 1.29-2.36). With the use of African-American women as the reference, Hispanic women were less likely than African-American women to experience any adverse pregnancy event, with the exception of gestational diabetes mellitus.
CONCLUSION: Poverty and insurance status does not explain differences in adverse pregnancy outcomes between African-American women and Hispanic women with Medicaid insurance.

Context Racial differences in survival have not been previously studied after in-hospital cardiac arrest, an event for which access to care is not likely to influence treatment. Objectives To estimate racial differences in survival for patients with in-hospital cardiac arrests and examine the association of sociodemographic and clinical factors and the admitting hospital with racial differences in survival. Design, Setting, and Patients Cohort study of 10 011 patients with cardiac arrests due to ventricular fibrillation or pulseless ventricular tachycardia enrolled between January 1, 2000, and February 29, 2008, at 274 hospitals within the National Registry of Cardiopulmonary Resuscitation. Main Outcome Measures Survival to hospital discharge; successful resuscitation from initial arrest and postresuscitation survival (secondary outcome measures). Results Included were 1883 black patients (18.8%) and 8128 white patients (81.2%). Rates of survival to discharge were lower for black patients (25.2%) than for white patients (37.4%) (unadjusted relative rate [RR], 0.73; 95% confidence interval [CI], 0.67-0.79). Unadjusted racial differences narrowed after adjusting for patient characteristics (adjusted RR, 0.81 [95% CI, 0.75-0.88]; P
.001) and diminished further after additional adjustment for hospital site (adjusted RR, 0.89 [95% CI, 0.82-0.96]; P=.002). Lower rates of survival to discharge for blacks reflected lower rates of both successful resuscitation (55.8% vs 67.4% for whites; unadjusted RR, 0.84 [95% CI, 0.81-0.88]) and postresuscitation survival (45.2% vs 55.5% for whites; unadjusted RR, 0.85 [95% CI, 0.79-0.91]). Adjustment for the hospital site at which patients received care explained a substantial portion of the racial differences in successful resuscitation (adjusted RR, 0.92 [95% CI, 0.88-0.96]; P
.001) and eliminated the racial differences in postresuscitation survival (adjusted RR, 0.99 [95% CI, 0.92-1.06]; P=.68). Conclusions Black patients with in-hospital cardiac arrest were significantly less likely to survive to discharge than white patients, with lower rates of survival during both the immediate resuscitation and postresuscitation periods. Much of the racial difference was associated with the hospital center in which black patients received care. JAMA. 2009;302(11):1195-1201 www.jama.com

Various authors have noted that interethnic group and intraethnic group racism are significant stressors for many African Americans. As such, intergroup and intragroup racism may play a role in the high rates of morbidity and mortality in this population. Yet, although scientific examinations of the effects of stress have proliferated, few researchers have explored the psychological, social, and physiological effects of perceived racism among African Americans. The purpose of this article was to outline a biopsychosocial model for perceived racism as a guide for future research. The first section of this article provides a brief overview of how racism has been conceptualized in the scientific literature. The second section reviews research exploring the existence of intergroup and intragroup racism. A contextual model for systematic studies of the biopsychosocial effects of perceived racism is then presented, along with recommendations for future research.

In the past decade, the reduction of health disparities has become an important policy agenda in the United States. Clinicians in practice, however, may be unfamiliar with the prevailing causal theories and uncertain about what they can do to help to reduce inequalities in health. The purpose of this article is to provide women’s health care clinicians with an overview of the definitions, measurement issues, and theories that fall under the rubric of health disparities. The intersecting roles of genetics, race/ethnicity, environment, and gender are discussed. The article also provides practical suggestions for interventions and health policy change that can be implemented by clinicians in practice. J Midwifery Womens Health 2009;54:57–64  2009 by the American College of Nurse-Midwives.

Since 1950, dramatic advances in human genetics have occurred, racial disparities in infant mortality have widened, and the United States' international ranking in infant mortality has deteriorated. The quest for a "preterm birth gene" to explain racial differences is now under way. Scores of papers linking polymorphisms to preterm birth have appeared in the past few years. Is this strategy likely to reduce racial disparities? We reviewed broad epidemiological patterns that call this approach into question. Overall patterns of racial disparities in mortality and secular changes in rates of prematurity as well as birth-weight patterns in infants of African immigrant populations contradict the genetic theory of race and point toward social mechanisms. We postulate that a causal link to class disparities in health exists.

African Americans have the highest rates of infant mortality and adverse birth outcomes of all major racial/ethnic groups in the US. The long-standing nature of this disparity suggests the need to shift epidemiologic focus from individual-level risk factors to the larger social forces that shape disease risk in populations. In this paper, the African American reproductive disadvantage is discussed within the context of American race relations. The review of the literature focuses on racism as a social determinant of race-based disparities in adverse birth outcomes with specific attention to the viability of genetic explanations, the role of socioeconomic factors, the multidimensional nature of racism, and the stress-induced physiologic pathways by which racism may negatively affect pregnancy. Implications for social work research and practice also are discussed.

OBJECTIVE: This study examined the role of psychosocial stress in racial differences in birth outcomes.
DESIGN: Maternal health, sociodemographic factors, and 3 forms of stress (general stress, pregnancy stress, and perceived racism) were assessed prospectively in a sample of 51 African American and 73 non-Hispanic White pregnant women. Main outcome measures: The outcomes of interest were birth weight and gestational age at delivery. Only predictive models of birth weight were tested as the groups did not differ significantly in gestational age.
RESULTS: Perceived racism and indicators of general stress were correlated with birth weight and tested in regression analyses. In the sample as a whole, lifetime and childhood indicators of perceived racism predicted birth weight and attenuated racial differences, independent of medical and socio-demographic control variables. Models within each race group showed that perceived racism was a significant predictor of birth weight in African Americans, but not in non-Hispanic Whites.
CONCLUSIONS: These findings provide further evidence that racism may play an important role in birth outcome disparities, and they are among the first to indicate the significance of psychosocial factors that occur early in the life course for these specific health outcomes.

Differential exposure to minority status stressors may help explain differences in United States (US)-born and foreign-born Black women’s birth outcomes.We explored self-reports of racism recorded in a survey of 185 US-born and 114 foreign-born Black pregnant women enrolled in Project Viva, a prospective cohort study of pregnant women in Boston, Massachusetts, USA. Self-reported prevalence of personal racism and group racism was significantly higher among US-born than foreign-born Black pregnant women, with US-born women having 4.1 and 7.8 times the odds, respectively, of childhood exposure. In multivariate analyses, US-born women’s personal and group racism exposure also was more pervasive across the eight life domains we queried. Examined by immigrant subgroups, US-born women were more similar in their self-reports of racism to foreign-born women who moved to the US before age 18 than to women who immigrated after age 18. Moreover, US-born women more closely resembled foreign-born women from the Caribbean than those from Africa. Differential exposure to self-reported racism over the life course may be a critically important factor that distinguishes US-born Black women from their foreign-born counterparts

In this column, the author reviews statistics that reflect the disparity of maternal mortality rates among black, nonwhite, and white women.

OBJECTIVES: We considered whether US Blacks experience early health deterioration, as measured across biological indicators of repeated exposure and adaptation to stressors.
METHODS: Using National Health and Nutrition Examination Survey data, we examined allostatic load scores for adults aged 18–64 years. We estimated probability of a high score by age, race, gender, and poverty status and Blacks’ odds of having a high score relative to Whites’ odds.
RESULTS: Blacks had higher scores than did Whites and had a greater probability of a high score at all ages, particularly at 35–64 years. Racial differences were not explained by poverty. Poor and nonpoor Black women had the highest and second highest probability of high allostatic load scores, respectively, and the highest excess scores compared with their male or White counterparts.
CONCLUSIONS: We found evidence that racial inequalities in health exist across a range of biological systems among adults and are not explained by racial differences in poverty. The weathering effects of living in a race-conscious society may be greatest among those Blacks most likely to engage in high-effort coping.

OBJECTIVES: To assess maternal health disparities, we compared maternal morbidities during labor and delivery among Mexican-born and US-born White, non-Latina women residing in California.
METHODS: This population-based study used linked hospital discharge and birth certificate data for 1996–1998 (862 723 deliveries). We calculated the frequency, and observed and adjusted odds ratios for obstetric complications. Covariates included maternal age, parity, education, prenatal care initiation and payment source, and hospital quality of care.
RESULTS: Approximately 1 in 5 deliveries resulted in a obstetric complication. After control for covariates, Mexican-born women were significantly less likely to have 1 or more maternal morbidities than White, non-Latina women but more likely to have complications that reflect the quality of intrapartum care.
CONCLUSIONS: Maternal morbidities during labor and delivery are a substantial burden for women in California. The favorable overall outcome of Mexican-born women over US-born White, non-Latinas is surprising given their lower educational attainment, relative poverty, and greater barriers to health care access. The favorable outcomes obscure vulnerabilities in those complications that are sensitive to the quality of intrapartum care.

OBJECTIVES: In 2003, California, Hawaii, Pennsylvania, Ohio (for births occurring in December only), Utah, and Washington provided to the National Center for Health Statistics (NCHS) multiple as well as single racial entries that mothers and fathers had reported on birth certificates in accordance with the revised race and ethnicity standards issued by the Office of Management and Budget (OMB) in 1997. This report provides detailed data on women reporting single race (one race) and multiple race (two or more races) by selected demographic and health characteristics (e.g., fertility, age at first birth, Hispanic ethnicity, marital status, country of birth, preterm birth, and low birthweight) of the women and their infants. Data presented in this report are derived from birth certificates from the five states that collected, reported, and transmitted to NCHS multiple-race data as of January 1, 2003 (California, Hawaii, Pennsylvania, Utah, and Washington). Data on selected demographic and health characteristics were analyzed comparing single-race mothers to multiple-race mothers.
METHODS: Descriptive tabulations of data reported on the birth certificates of the single- and multiple-race births that occurred in the reporting area in 2003 are presented.
RESULTS: In 2003, 2.5 percent of births in California, Hawaii, Pennsylvania, Utah, and Washington were to women who reported two or more races, with levels varying from 1 (Utah) to 33 percent (Hawaii). Birth and fertility rates for single-race (one race) groups were generally lower than the rates for multiple-race groups (each race in combination with one or more other races), whereas age at first birth was generally higher for single-race women than for multiple-race women. The percentages of Hispanic births to single-race black, American Indian or Alaska Native (AIAN), Asian, and Native Hawaiian or Other Pacific Islander (NHOPI) women were lower than the percentage for women reporting those races in combination with one or more of the other races (multiple race). The percentage of births to unmarried women was higher among single-race black and AIAN women compared with multiple-race black and AIAN women, whereas the proportions were considerably higher for multiple-race white, Asian, and NHOPI women than for their single-race counterparts. The percentage of mothers born in the 50 states and the District of Columbia was consistently higher for multiple-race women than single-race women. In terms of infant health characteristics, infants of single-race white and Asian women had a lower preterm birth rate than infants of multiple-race white and Asian women, whereas infants of single-race black and AIAN women had higher preterm rates than infants of multiple-race black and AIAN women. The low birthweight rate was also significantly lower for single-race white, Asian, and NHOPI women than their multiple-race counterparts. In comparison, the rate for single-race black women was higher than the rate for multiple-race black women.

PURPOSE: African-American women have a 2- to 4-fold increased risk of pregnancy-related death compared with Caucasian women. We conducted this study to determine if differences in a combination of socioeconomic and medical risk factors may explain this racial disparity in pregnancy-related death.
METHODS: Pregnancy-related deaths of African-American (N=60) and Caucasian (N=47) women were identified from review of pregnancy-associated deaths (N=400) ascertained through cause of death on death certificates, electronic linkage of birth and death files, and review of the hospital discharge database for the State of North Carolina, during the period between 1992 and 1998. Controls (N=3404) were randomly selected from all live births for the same 7-year period. Logistic regression was used to model the association between race and pregnancy-related death.
RESULTS: The unadjusted odds ratio (OR) for pregnancy-related death for African-Americans compared with Caucasians was 3.07 (95% confidence interval [CI], 2.08, 4.54). After controlling for gestational age at delivery, maternal age, income, hypertension, and receipt of prenatal care, African-American race remained a significant predictor variable (OR 2.65 [95% CI 1.73, 4.07]).
CONCLUSIONS: Our analysis confirms that there is a strong association between race and pregnancy-related death, even after adjusting for potential predictors and confounders.

PURPOSE: Our study aim was to identify factors that may contribute to the racial disparity in pregnancy-related mortality.
METHODS: We examined differences in severity of disease, comorbidities, and receipt of care among 608 (304 African-American and 304 white) consecutive patients of non-Hispanic ethnicity with one of three pregnancy-related morbidities (pregnancy-related hypertension, puerperal infection, and hemorrhage) from hospitals selected at random from a statewide region.
RESULTS: African-American women had more severe hypertension, lower hemoglobin concentrations preceding hemorrhage, more antepartum hospital admissions, and a higher rate of obesity. The rate of surgical intervention for hemorrhage was lower among African-Americans, although the severity of hemorrhage did not differ between the two racial groups. More African-American women received eclampsia prophylaxis. After stratifying by severity of hypertension, we found that more African-Americans received antihypertensive therapy. The rate of enrollment for prenatal care was lower in the African-American group. Among women receiving prenatal care, African-American women enrolled significantly later in their pregnancies.
CONCLUSIONS: We have identified racial differences in severity of disease, comorbidities, and care status among women with pregnancy-related complications that would place African-Americans at disadvantage to survive pregnancy. These differences are potentially modifiable.

A growing body of researchexplores the impact of encounters with racism or discrimination on physiological activity. Investigators have collected these data in laboratories and in controlled clinical settings. Several but not all of the studies suggest that higher blood pressure levels are associated with the tendency not to recall or report occurrences identified as racist and discriminatory. Investigators have reported that physiological arousal is associated with laboratory analogues of ethnic discrimination and mistreatment. Evidence from survey and laboratory studies suggests that personality variables and cultural orientation moderate the impact of racial discrimination. The neural pathways that mediate these physiological reactions are not known. The evidence supports the notion that direct encounters with discriminatory events contribute to negative health outcomes. (Am J Public Health. 2003;93:243–248)

Objective: To extend findings that African American women report greater stress during pregnancy, have higher blood pressure (BP), and are twice as likely to have low birthweight infants relative to white women. This study examines a) racial differences in associations between stress and BP during pregnancy, and b) the combined effects of stress and BP on infant birthweight in a sample of 170 African American and white women. Methods: A prospective, longitudinal study of pregnant women was conducted in which measures of BP, stress, and other relevant variables were collected. Multiple measures of systolic and diastolic BP were taken at each of three points during pregnancy (18 –20, 24–26, and 30–32 weeks gestation). Results: Both systolic blood pressure (SBP) and diastolic blood pressure (DBP) were positively associated with stress in pregnant African American women and not in pregnant white women. In analyses of birthweight, there were no main effects of BP or stress. However, a significant interaction demonstrated that, when stress was high, DBP was negatively associated with birthweight and a combination of high stress and high DBP predicted the lowest birthweight in the sample. Furthermore, African American women were twice as likely as white women to have a combination of high stress and high DBP. Conclusions: Racial differences in relationships between stress and BP, and the interactive effect of stress and DBP on birthweight together suggest that a high stress-high BP profile may pose a risk for lower birthweight among African American women, in particular, and possibly for all pregnant women. Key words: pregnancy, birthweight, African American, blood pressure, stress.

The disparity between blacks and whites in perinatal health ranges from a 2.3-fold excess risk among black women for preterm delivery and infant mortality to a 4-fold excess risk among black women for maternal mortality. To stimulate concerted public health action to address such racial and ethnic disparities in health, the national Healthy People objectives call for elimination of all health disparities by the year 2010. Eliminating health disparities requires a greater understanding of the factors that contribute to their development. This commentary summarizes the state of the science of reducing such disparities and proposes a framework for using the results of qualitative studies on the social context of pregnancy to understand, study, and address disparities in infant mortality and preterm delivery. Understanding the social context of African American women's lives can lead to an improved understanding of the etiology of preterm birth, and can help identify promising new interventions to reduce racial and ethnic disparities in preterm delivery.

Over 60 years ago, Selye recognized the paradox that the physiologic systems activated by stress can not only protect and restore but also damage the body. What links these seemingly contradictory roles? How does stress influence the pathogenesis of disease, and what accounts for the variation in vulnerability to stress-related diseases among people with similar life experiences? How can stress-induced damage be quantified? These and many other questions still challenge investigators. This article reviews the long-term effect of the physiologic response to stress, which I refer to as allostatic load. Allostasis—the ability to achieve stability through change—is critical to survival. Through allostasis, the autonomic nervous system, the hypothalamic–pituitary–adrenal (HPA) axis, and the cardiovascular, metabolic, and immune systems protect the body by responding to internal and external stress. The price of this accommodation to stress can be allostatic load, which is the wear and tear that results from chronic overactivity or underactivity of allostatic systems.

Introduction: Reducing racial/ethnic disparities is a key objective of the Healthy People 2010 initiative. Unfortunately, racial disparities among women delaying initiation of childbearing have received limited attention. As more women in the US are delaying initiation of childbearing, it is important to examine racial disparities in reproductive health outcomes for this subgroup of women. Objective: To examine racial disparities in perinatal outcomes, interpregnancy interval, and to assess the risk for adverse outcomes in subsequent pregnancy for women delaying initiation of childbearing until age 30 or older compared to those initiating childbearing at age 20-29. Methods: We conducted a retrospective cohort study using the Missouri maternally linked cohort files 1978-1997. Final study sample included 239,930 singleton sibling pairs (Whites and African Americans). Outcome variables included first and second pregnancy outcomes (fetal death, low birth weight, preterm delivery and small-for-gestational age) and interpregnancy interval between first and second pregnancy. Independent variables included maternal age at first pregnancy and race. Analysis strategies used involved stratified analyses and multivariable unconditional logistic regression; interactions between maternal race, age and interpregnancy interval were examined in the regression models. Results: Compared to Whites, African American mothers initiating childbearing at age 30 or older had significantly higher rates of adverse outcomes in the first and second pregnancy (P < 0.0001). Generally, African Americans had significantly higher rates of second pregnancy following intervals <6 months compared to Whites; however, no significant racial differences were noted in interpregnancy interval distribution pattern after controlling for maternal age at first pregnancy. African Americans delaying initiation of childbearing had significantly higher risk for adverse perinatal outcomes in the second pregnancy compared to Whites after controlling for potential confounders, however there were no significant interactions between maternal age at first pregnancy, race and short interpregnancy interval. Conclusion: Although African Americans were less likely to delay initiation of childbearing than were White women, their risk for adverse perinatal outcomes was much greater. As health care providers strive to address racial disparities in birth outcomes, there is need to pay attention to this unique group of women as their population continues to increase.

The authors conducted a nested case-control study to determine whether the fourfold increased risk of pregnancy-related mortality for US Black women compared with White women can be explained by racial differences in sociodemographic and reproductive factors. Cases were derived from a national surveillance database of pregnancy-related deaths and were restricted to White women (n = 840) and Black women (n = 448) whose pregnancies resulted in a livebirth and who died of a pregnancy-related cause between 1979 and 1986. Controls were derived from national natality data and were randomly selected White women and Black women who delivered live infants and did not die from a pregnancy-related cause (n = 5,437). Simultaneous adjustment for risk factors by using logistic regression did not explain the racial gap in pregnancy-related mortality. The largest racial disparity occurred among women with the lowest risk of pregnancy-related death: those of low to moderate parity who delivered normal-birth-weight babies (adjusted odds ratio = 3.53, 95% confidence interval: 2.9, 4.4). In contrast, no racial disparity was found among women with the highest risk of pregnancy-related death: high-parity women who delivered low-birth-weight babies. These findings indicate that reproductive health care professionals need to develop strategies to reduce pregnancy-related deaths among both high- and low-risk Black women.

In this article, the authors draw on the disciplines of sociology and environmental and social epidemiology to further understanding of mechanisms through which social factors contribute to disparate environmental exposures and health inequalities. They propose a conceptual framework for environmental health promotion that considers dynamic social processes through which social and environmental inequalities--and associated health disparities--are produced, reproduced, and potentially transformed. Using empirical evidence from the published literature, as well as their own practical experiences in conducting community-based participatory research in Detroit and Harlem, the authors examine health promotion interventions at various levels (community-wide, regional, and national) that aim to improve population health by addressing various aspects of social processes and/or physical environments. Finally, they recommend moving beyond environmental remediation strategies toward environmental health promotion efforts that are sustainable and explicitly designed to reduce social, environmental, and health inequalities.

OBJECTIVE: To describe maternal deaths and 10-year trends in maternal mortality in New York City.
METHODS: All maternal deaths reported by surveillance of vital records (bearing ICD-9 codes 630-676) in New York City between 1989 and 1998 were studied. Were viewed death certificates and medical and autopsy records to collect age, race/ethnicity, country of birth, marital status, education level, residence at time of death, cause of death, and outcome of pregnancy. Trends analysis for maternal mortality rates was conducted, stratified by race. We conducted univariate and multivariate analysis to identify risk factors for maternal death.
RESULTS: Two hundred forty-three maternal deaths were reported, for an average maternal mortality rate (MMR) of 18.4 deaths per 100,000 live births during this period. Although the overall MMR decreased from 17.4 in 1989 to 13.7 in 1998, the MMR varied widely during the period with a non significant trend (x2 for trend 2.09, p=.15). However, the individual MMR for whites and blacks decreased significantly from 1989 to 1998. The black-white MMR ratio remained high throughout this period and varied from 2.2 in 1994 to 14.8 in 1998. Women who were 35 years of age or older or non-Hispanic black had an increased risk of a pregnancy-related death. The leading causes of death were hemorrhage, embolism, and infection.
CONCLUSION: Racial disparity in maternal mortality is a cause for concern in New York City. Further studies of maternal mortality are needed to develop interventions to reduce the MMR and the black-white gap.

Objectives: We studied trends of hypertensive disorders of pregnancy by residential socioeconomic status (SES) and racial/ethnic subgroups in New York State over a 10-year period. Methods. We merged New York State discharge data for 2.5 million women hospitalized with delivery from 1993 through 2002 with 2000 Census data. Results. Rates of diagnoses for all hypertensive disorders combined and for preeclampsia individually were highest among Black women across all regions and neighborhood poverty levels. Although hospitalization rates for preeclampsia decreased over time for most groups,, differences in rates between White and Black women increased over the 10-year period. The proportion of women living n poor areas remained relatively constant over the same period. Black and Hispanic women were more likely than White women to have a form of diabetes and were at higher risk of preeclampsia; preeclampsia rates were higher in these groups both with and without diabetes than in corresponding groups of White women. Conclusions. An increasing trend of racial/ethnic disparity in maternal hypertension rates occurred in New York State during the past decade. This trend was persistent after stratification according to SES and other risk factors. Additional research is needed to understand the factors contributing to this growing disparity (Am J Public Health.2007;97:163-170, dpi 10.2105/AJPH.2005.068577)

ABSTRACT: This article provides an overview of the evidence on the ways racism can affect the disproportionate rates of cardiovascular disease (CVD) in African Americans. It describes the significant health disparities in CVD for blacks and whites and suggests that racial disparities should be understood within the context of persistent inequities in societal institutions and relations. Evidence and potential pathways for exploring effects of 3 levels of racism on cardiovascular health risk factors and outcomes are reviewed. First, institutional racism can lead to limited opportunities for socioeconomic mobility, differential access to goods and resources, and poor living conditions that can adversely affect cardiovascular health. Second, perceived/personally mediated racism acts as a stressor and can induce psychophysiological reactions that negatively affect cardiovascular health. Third, in race-conscious societies, such as the United States, the negative self-evaluations of accepting negative cultural stereotypes as true (internalized racism) can have deleterious effects on cardiovascular health. Few population-based studies have examined the relationship between racism and CVD. The findings, though suggestive of a positive association, are neither consistent nor clear. The research agenda of the Jackson Heart Study in addressing the role of racism in CVD is presented. Race; Racism; Stress; Discrimination; Cardiovascular disease; Hypertension; Behavioral risk factors; Ethnicity; Jackson Heart Study. [Am J Med Sci 2003;325(6):315–331.]

2006 National Healthcare Disparities Report—At A Glance For most core quality measures, Blacks (73%), Hispanics (77%), and poor people (71%) received worse quality care than their reference groups. For most measures for poor people (67%), disparities were incre a s i n g; for most measures for minorities, significant changes in disparities were not observed. Increasing disparities were especially prevalent in chronic disease management. Compared to their reference groups— • Blacks had 90% more lower extremity amputations for diabetes. • Asians were restrained in nursing homes 46% more often. • American Indians and Alaska Natives were hospitalized from home health care 15% more often. • Hispanics had 63% more pediatric asthma hospitalizations. • Poor people were 37% less likely to receive recommended diabetes care. All of these disparities were increasing over time. However, better and improving quality was also observed for at least 1 measure for eve ry population. For most core access measures, Hispanics (83%) and poor people (100%) had worse access to care than their reference groups. Disparities were increasing for most measures for Hispanics (80%) and poor people (60%). Better access was only observed for Asians compared with Whites, although improving access was observed for at least 1 measure for eve ry population

The Institute of Medicine Report Crossing the Quality Chasm was truly transformative in that it presented our nation with a blueprint for achieving quality. The report urges us to focus on six key areas to deliver on our promise of high-quality care: efficiency, effectiveness, safety, timeliness, patient-centeredness, and equity. Hospitals across the country have heeded the Institute of Medicine’s call, and are actively engaged in trying to improve quality – yet, we would be remiss to view any one area of quality as less important than another. This brings me to the issue of equity. The fact that racial and ethnic minorities in this country may receive poorer quality health care than their white counterparts in hospitals across the country — even when they have health insurance — is indisputable and undeniable. The evidence, so eloquently presented in another Institute of Medicine Report Unequal Treatment, clearly points to the fact that the issue of racial and ethnic disparities in health care is an inequality in quality that deserves our utmost attention. It is therefore no coincidence that equity is a key pillar of quality. Although conceiving the notion of unequal treatment can be uncomfortable, and to some unimaginable, given the evidence, it is incumbent upon us to assume that we have disparities in our own institutions unless proven otherwise. The importance of collecting patient race and ethnicity data, developing monitoring and reporting tools, and creating interventions to address disparities when found — as Unequal Treatment recommends — cannot be overstated. At Massachusetts General Hospital, we have taken this issue very seriously. Equity receives equal attention to the other pillars of quality from the Board room to the exam room. Our leadership understands that we cannot improve quality without improving equity, and we have engaged in a process of building the systems and interventions necessary to make this a reality. Ultimately, we believe that improving quality, addressing disparities and achieving equity is our responsibility, and that these efforts will improve not just the care of minorities, but of all patients at our institution. For those who are interested in better understanding the issue of disparities, and why it is a key component of quality, this Guide for Hospital Leaders will provide some concrete answers. In addition to presenting the evidence for disparities and the rationale for addressing them, it also gives a view from the field, as well as a guide on how to initiate a portfolio of action in this area. Built on research, real world experiences, and national examples and models, this first-of-a-kind guide is practical, respectful of competing interests and pressures, and strategic — a perfect resource for getting started. Whether you are a CEO and need some background and guidance, or an advocate in need of a tool to convince your leadership to care and act, this guide will meet your needs. As we move ahead, we can see that there is a quality, safety, cost, and risk management case for addressing disparities. If that is not enough, the changing demographics of the U.S., new pay-for-performance efforts targeting disparities, and the Joint Commission and National Quality Forum’s recent attention to these issues, clearly highlight that achieving equity isn’t just the right thing to do, it’s an important ingredient to business success in health care. This guide can help you map out a successful strategy to improve quality, achieve equity, and address racial and ethnic disparities in health care. I urge my counterparts to take on this important area of work and join me and other hospital leaders across the country who are striving to meet the challenge of achieving equity and assuring high-quality care for all we serve. Peter Slavin, MD President Massachusetts General Hospital

Although the health of all Americans has continued to improve over the more than two decades since the 1985 Task Force Report on Black and Minority Health was issued, racial and ethnic health disparities persist and, in some cases, are increasing. The persistence of such disparities suggests that current approaches and strategies are not producing the kinds of results needed to ensure that all Americans are able to achieve the same quality and years of healthy life, regardless of race/ethnicity, gender and other variables (as reflected in the two overarching goals of Healthy People 2010). The mission of the HHS Office of Minority Health (OMH) is to improve the health of racial and ethnic minority populations through the development of health policies and programs that will help eliminate disparities. OMH has a unique leadership and coordination role to play within the Department and across the nation, relative to this mission. However, such a mission cannot be accomplished by OMH alone. We need the active engagement and sustained efforts of all stakeholders working together with us and each other to effect the necessary changes at every level and across all sectors over time. These stakeholders include racial and ethnic minority communities and those who serve them, other HHS and Federal entities, academic and research institutions, State and Tribal governments, faith- and community-based organizations, private industry, philanthropies and many others. We also need to examine what we are doing, identify what must be done differently and determine how best to work together - within and across our respective disciplines, areas of interest, organizational/institutional or geographic boundaries and spheres of influence - to enhance our individual and collective effectiveness and impacts. The Strategic Framework for Improving Racial and Ethnic Minority Health and Eliminating Racial and Ethnic Health Disparities (Framework) presented here is intended to help guide, organize and coordinate the systematic planning, implementation and evaluation of efforts within OMH, HHS and across the nation to achieve better results relative to minority health improvements and health disparities reductions. The Framework reflects current knowledge and understanding of the nature and extent of health disparities, their causes or contributing factors, effective solutions and desired outcomes and impacts. It reinforces the importance of having and using science and knowledge as the basis for planning and implementing our program-, research-, or policy-oriented actions and activities. The Framework also suggests the need to adequately evaluate our efforts so that new knowledge can be used for continuous improvement. In addition, the Framework infers the need to fund our efforts accordingly, and to explore ways to enhance efficient use of programmatic and research funds as well as other resources and assets at our disposal. Several aspects of this framework are worth highlighting: 1. By using a logic model approach, which builds upon current science and expert consensus about racial/ethnic minority health/health disparities and systems problems, contributing or causal factors and strategies that work, the Framework provides the rationale for efforts funded and conducted as well as for the kinds of outcomes and impacts needed . This approach can be used as a guide to move us toward a common set of objectives and goals. 2. In addition to identifying the usual determinants of health, the Framework emphasizes the role that "systems-level factors" play in promoting or inhibiting the effectiveness of strategies and practices aimed at improving racial and ethnic minority health or reducing racial and ethnic health disparities. These systems factors include: the nature and extent of available resources and how they are used, coordination and collaboration through partnerships and communication, leadership and commitment through strategic visioning and sustained attention, user-centered design in which the products and services of the system are conceived with the needs of their users in mind and the use of science and knowledge to inform programs and policies. 3. Ultimately, the Framework presents a vision – and provides the basis - for a "systems approach" to addressing racial/ethnic minority health problems within and outside of HHS. A systems approach implies that all parties engaged, in this case, in racial/ethnic minority health improvement and health disparities reduction are, themselves, part of a 'system' or 'nested' systems. As such, each party considers the causal or contributing factors and problems it is most likely to be able to impact with its particular strengths and talents. Resources and assets can then be coordinated and leveraged in more systematic and strategic ways, to achieve a range of outcomes and impacts needed so that, together, all parties can more effectively and efficiently contribute to and achieve long-term objectives and goals. This focus on systems applies as well to how various fields of research work together for greater effectiveness and efficiency to address weaknesses and gaps in scientific knowledge. A systems approach to working across diverse research disciplines may be better able to illuminate our understanding about the nature and extent of minority health and health disparities problems, especially for small population groups, the relative importance of and interrelationships between causal or contributing factors, more effective ways to break the causal chain that produces greater burdens of preventable disease and premature death among racial and ethnic minorities and the means for measuring desired outcomes and assessing progress. We believe that the structure and approach outlined in the Framework offers a rational and systematic, yet broad and flexible, way of viewing and informing our efforts to achieve the OMH and, in reality, the national mission. We hope that the Framework will provide context for the actions needed by OMH and its partners across HHS and the nation to better leverage resources, establish priorities for ensuring effectiveness of programs and activities funded and conducted, enable identification and promotion of best practices and concrete solutions at all levels and serve as the foundation for a national results-oriented culture on racial and ethnic minority health improvement and the elimination of racial and ethnic health disparities.

Two slides on Pregnancy-Related Mortality Rates by Nativity (US born or foreign born) for Latina California Residents: 1990-2004.

The Safe Motherhood Initiative is a joint project of the American College of Obstetricians and Gynecologists District II/New York in collaboration with the Bureau of Women’s Health of the New York State Department of Health. Established in 2001, the mission of the Initiative is to help prevent pregnancy-related deaths through improved understanding of the causes and risk factors for maternal mortality. Utilizing the maternal death protocol and accompanying abstraction form developed in year one, the Safe Motherhood Initiative and the state’s Regional Perinatal Centers conduct quality assurance and quality improvement activities related to maternal mortality. The Initiative was inspired by the signifi cant racial disparities associated with maternal mortality. The key strategies for prevention of maternal deaths in New York State include the development of a standardized system to report and review pregnancy-related deaths along with the provision of recommendations and training that have the direct goal of improving maternity care.