AHRQ report underscores disparities in maternal morbidity

September 18, 2018
Judith M. Orvos, ELS

a BELS-certified medical writer and editor, and an editorial consultant for Contemporary OB/GYN

,
Ben Schwartz

Ben Schwartz is Associate Editor, Contemporary OB/GYN.

A new report shows that over a 10-year period in the United States, rates of severe maternal morbidity increased and age, race, and income, all played a role in disparities in specific related trends. PLUS: How are most women informed of a breast cancer diagnosis? ALSO: Does gestational diabetes signal long-term risk for mothers and their children?

A new report from the Agency for Healthcare Research and Quality (AHRQ) shows that over a 10-year period in the United States, rates of severe maternal morbidity increased. Age, race, and income, the authors found, all played a role in disparities in specific related trends.

The data, spanning 2006 through 2015, are reviewed in an AHRQ Healthcare Cost and Utilization Project (HCUP) Statistical Brief. The analysis file used was derived from the HCUP State Inpatient Databases (SID) and weighted to provide national estimates calculated with the same methodology as the Nationwide Inpatient Sample (NIS). SID encompasses more than 95% of all US community hospital discharges; NIS is nationally representative of all community hospitals.

For the analysis, severe maternal morbidity was defined using 21 indicators developed by the Centers for Disease Control and Prevention, including conditions and procedures performed during a woman’s hospital stay. Between 2006 and 2015, the rate of severe maternal morbidity increased 45%--from 101.3 to 146.6 per 10,000 delivery hospitalizations. Blood transfusion, disseminated intravascular coagulation and hysterectomy were the most common indicators of that morbidity.

Looking at factors related to severe maternal morbidity, the authors found trends associated with age, race, and income. Rates were highest in women aged ≥ 40 and lowest in those aged 20 to 29. Black women had rates of severe maternal morbidity 112% to 115% higher than for white women (164 vs 176 in 2006 and 241 vs 114 in 2006 and 2015, respectively). 

Over time, deaths among women of all races and ethnicities declined, but in 2015, in-hospital mortality was three times higher for black women than for white women. Women who were on Medicaid or uninsured also had higher rates of severe maternal morbidity on delivery than those who had private insurance (176.5 and 175.0 per 10,000 delivery hospitalizations for Medicaid and uninsured versus private insurance, respectively).  

Blood transfusion was the most common indicator of severe maternal morbidity and performed in approximately 80% of cases reflected in the data file. Deliveries complicated by severe maternal morbidity also were more likely to occur at hospitals that typically serve vulnerable populations-safety-net (43.6% vs 35.1%) and minorities (53.4% vs 44.3%). Geographically, those deliveries tended to be in the northeast and south rather than in the midwest or west.

Overall, black and Hispanic women and women of other races and ethnicities were overrepresented among deliveries involving severe maternal morbidity, as compared with white women. 

How are most women informed of a breast cancer diagnosis?

A cancer diagnosis is life-altering, but a study in Supportive Care in Cancer has found an alarming trend in how these women with breast cancer are receiving the news. The findings are based on an analysis of surveys given to nearly 3,000 women from the Dr. Susan Love Research Foundation’s Army of Women cohort.  

The survey recipients received a cancer diagnosis between 1967 and 2017 and took a survey that included demographic questions and questions about their diagnosis. The study authors asked whether the women were told they had breast cancer over the phone or in person alone, with a significant other, family member or with a friend. 

Using a multivariable logistic regression model, the authors found that the participants were more likely to be given their diagnosis over the telephone in more recent years (OR 1.07, 95% CI 1.06-1.08) or when being told about in situ versus metastatic disease (OR 1.73, 95% CI 1.02-2.93). However, participants who did not have post-diagnosis support from family, friends, or professional groups were less likely to receive a diagnosis over the phone (OR 0.30, 95% CI 0.13-0.68) compared to those who identified a spouse as source of support. 

Participants who identified as a sexual minority (OR.70, 95% CI 0.48-0.99) were also less likely to receive a diagnosis by phone call compared to heterosexual women. The authors also said that notification by telephone has increasingly become more prevalent since 2006. From 1967 to 2007, approximately 25% of the participants reported learning of their diagnosis over the phone, with the remainder learning in person. In the last 10 years (2008-2017), over 50% of participants reported learning of their diagnosis over the phone. 

The majority of the participants were white (93%) and were married/domestic partners/living with a partner at the time of breast cancer diagnosis (81%). Five percent of the participants self-identified as lesbian, bisexual, or something else (queer, asexual, polysexual, etc). The median age of the participants was 51 years (range 23-85 years). Sixteen percent of the participants responded as having more than one breast cancer diagnosis and a similar number (19%) was currently in treatment or within 1 year of completing their primary breast cancer treatment. The majority of respondents (78%) reported that their cancer was invasive, stage 1, or stage 2. 

Their findings, the authors said, are consistent with similar studies on cancer diagnosis delivery, although the other studies differed in what patients preferred. An Australian study found that the majority (77%) of patients preferred an in-person diagnosis of cancer, while an American study found that patients prioritized timeliness in their diagnosis and wanted the results as quickly as possible. 

Limitations of the current study included a self-selected study population that was either diagnosed with breast cancer or interested in breast cancer research and largely white and heterosexual, which may not reflect the experiences of racial/ethnic or sexual minority women, as well as self-reporting of data. The participants also were much younger (mean age 51 years) than those with a breast cancer diagnosis (62 years) in the United States. The authors believe that while their empirical data show changing trends in how women are informed about breast cancer diagnosis, more research is needed to determine the best way to deliver such news.

Does gestational diabetes signal long-term risk for mothers and their children?

study in JAMA suggests that untreated gestational diabetes (GD) may be associated with long-term health risks for both mothers and their offspring. The findings are from research done as a follow-up to the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study. 

HAPO showed that prenatal glucose levels during a 2-hour 75-g oral glucose tolerance test (OGTT) lower than those diagnostic of diabetes were associated with adverse pregnancy outcomes along a continuum. The follow-up study was done to look at associations between GD and maternal glucose metabolism and adiposity in their children 10 to 14 years after birth.

The participants for the follow-up study were originally examined between February 13, 2013 and December 13, 2016 and were eligible for the follow-up if they remained blind to the results of the OGTT, gestational age at delivery was ≥ 37 week, and the pregnancy did not involve any major fetal or neonatal malformations or death. GD was defined post hoc as fasting plasma glucose ≥ 92 mg/dL; 1-hour plasma glucose level ≥ 180 mg/dL; or 2-hour plasma glucose level ≥ 153 mg/dL. 

During the follow-up study visit, participants had their height, weight, waist circumference, and skin folds (triceps, subscapular, and suprailiac) measured. In addition, Tanner staging was performed in the children using breast development or testicular volume. The mothers underwent a 2-hour 75-g OGTT after an 8-hour overnight fast. 

Of 15,812 eligible mother-child pairs, 4,832 children (mean [SD] age, 11.4 [1.2] years; 51% male) and 4,697 mothers (mean [SD] 41.7 [5.7] years) were included in the follow-up study. The criteria for GD were met by 14.3% (683/4697) of mothers, 345 of whom (51.3%) met fasting plasma glucose level criteria, 344 of whom (51.2%) met 1-hour plasma glucose level criteria, and 239 of whom (35.6%) met 2-hour plasma glucose level criteria. 

Among mothers with GD, 52.2% (346/663) developed a glucose disorder vs 20.1% of mothers (791/3946) without GD (odds ratio [OR], 3.44 [95% CI, 2.85-4.14]; risk difference [RD], 25.7%, [95% CI, 21.7%-29.7%]). Among children of mothers with GD, 39.5% (269/681) were overweight or obese and 19% (130/681) were obese compared with 28.6% (1172/4094) and 9.9% (405/4094), respectively, for children of mothers without GD. After adjusting for maternal body mass index (BMI) during pregnancy, the OR was 1.21 (95% C, 1.00-1.46) for children who were obese and the RD was 3.7% (95% CI, –0.16%-7.5%). 

The authors noted a few limitations to their study. Not all eligible participants met International Association of the Diabetes and Pregnancy Study Group criteria for GD. Also, data on maternal BMI were collected at the time of OGTT during pregnancy rather than in pregestation. Postnatal lifestyle data were not available. The authors found that women who had GD were at a significantly higher risk for developing glucose metabolism disorders later in life but their children were not at a significantly higher risk for adiposity compared to children of mothers without GD. However, they believe that more research, specifically on additional measures of childhood adiposity, is necessary to fully understand the f