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Trends and Disparities in Severe Maternal Morbidity Indicator Categories During Childbirth Hospitalization in California from 1997-2017

El Ayadi, Alison M; Lyndon, Audrey; Kan, Peiyi; Mujahid, Mahasin S; Main, Elliott K; Carmichael, Suzan
Objective Severe maternal morbidity (SMM) is increasing and characterized by substantial racial and ethnic disparities. Analyzing trends and disparities across time by etiologic or organ system groups instead of an aggregated index may inform specific, actionable pathways to equitable care. We explored trends and racial and ethnic disparities in seven SMM categories at childbirth hospitalization. Study Design We analyzed California birth cohort data on all live and stillbirths ≥20 weeks gestation from 1997-2017 (n=10,580,096) using the Centers for Disease Control and Prevention's SMM index. Cases were categorized into seven non-mutually exclusive indicator categories (cardiac, renal, respiratory, hemorrhage, sepsis, other obstetric, and other medical SMM). We compared prevalence and trends in SMM indicator categories overall and by racial and ethnic group using logistic and linear regression. Results SMM occurred in 1.16% of births and non-transfusion SMM in 0.54%. Hemorrhage SMM occurred most frequently (27 per 10,000 births), followed by other obstetric (11), respiratory (7), and sepsis, cardiac, and renal SMM (5). Hemorrhage, renal, respiratory, and sepsis SMM increased over time for all racial and ethnic groups. The largest disparities were for Black individuals, including over three-fold increased odds of other medical SMM. Renal and sepsis morbidity had the largest relative increases over time (717% and 544%). Sepsis and hemorrhage SMM had the largest absolute changes over time (17 per 10,000 increase). Disparities increased over time for respiratory SMM among Black, US-born Hispanic, and non-US-born Hispanic individuals and for sepsis SMM among Asian or Pacific Islander individuals. Disparities decreased over time for sepsis SMM among Black individuals yet remained substantial. Conclusion Our research further supports the critical need to address SMM and disparities as a significant public health priority in the United States and suggests that examining SMM subgroups may reveal helpful nuance for understanding trends, disparities and potential needs for intervention.
PMID: 38057087
ISSN: 1098-8785
CID: 5591072

A Qualitative Study of Breastfeeding Experiences Among Mothers Who Used Galactagogues to Increase Their Milk Supply

Ryan, Rachel A.; Hepworth, Allison Doub; Bihuniak, Jessica Dauz; Lyndon, Audrey
Objective: To qualitatively describe breastfeeding experiences among mothers who used galactagogues to increase their milk supply. Design: One-time, semistructured phone interviews. Setting: US. Participants: Breastfeeding mothers (n = 19) who reported ever consuming foods, beverages, or herbal supplements to increase their milk supply in a cross-sectional online survey were purposefully sampled to participate in this qualitative study. Participants were diverse in terms of race and ethnicity, education, income, infant age (0"“18 months), and prior breastfeeding experience (32% first-time breastfeeding). Phenomenon of Interest: Reasons for trying to increase milk supply, sources of information about increasing milk supply, and strategies tried to increase milk supply. Analysis: Interviews were transcribed verbatim and analyzed using reflexive thematic analysis. Results: Participants expressed determination and commitment to breastfeeding but unexpectedly struggled to breastfeed and increase their milk supply. They sought information from multiple sources and used individualized approaches to address milk supply concerns on the basis of recommendations from others, as well as the perceived convenience, cost, palatability, and safety of potential strategies. Conclusions and Implications: Results suggest a need to expand breastfeeding education and support so that lactating parents anticipate common breastfeeding challenges and are aware of evidence-based strategies for increasing their milk supply.
SCOPUS:85181096664
ISSN: 1499-4046
CID: 5630382

Assessing the relationship between census tract rurality and severe maternal morbidity in California (1997-2018)

Berkowitz, Rachel L; Kan, Peiyi; Gao, Xing; Hailu, Elleni M; Board, Christine; Lyndon, Audrey; Mujahid, Mahasin; Carmichael, Suzan L
PURPOSE/OBJECTIVE:Recent studies have demonstrated an increased risk of severe maternal morbidity (SMM) for people living in rural versus urban counties. Studies have not considered rurality at the more nuanced subcounty census-tract level. This study assessed the relationship between census-tract-level rurality and SMM for birthing people in California. METHODS:We used linked vital statistics and hospital discharge records for births between 1997 and 2018 in California. SMM was defined by at least 1 of 21 potentially fatal conditions and lifesaving procedures. Rural-Urban Commuting Area codes were used to characterize census tract rurality dichotomously (2-category) and at 4 levels (4-category). Covariates included sociocultural-demographic, pregnancy-related, and neighborhood-level factors. We ran a series of mixed-effects logistic regression models with tract-level clustering, reporting risk ratios and 95% confidence intervals (CIs). We used the STROBE reporting guidelines. FINDINGS/RESULTS:Of 10,091,415 births, 1.1% had SMM. Overall, 94.3% of participants resided in urban/metropolitan and 5.7% in rural tracts (3.9% micropolitan, 0.9% small town, 0.8% rural). In 2-category models, the risk of SMM was 10% higher for birthing people in rural versus urban tracts (95% CI: 6%, 13%). In 4-category models, the risk of SMM was 16% higher in micropolitan versus metropolitan tracts (95% CI: 12%, 21%). CONCLUSION/CONCLUSIONS:The observed rurality and SMM relationship was driven by living in a micropolitan versus metropolitan tract. Increased risk may result from resource access inequities within suburban areas. Our findings demonstrate the importance of considering rurality at a subcounty level to understand locality-related inequities in the risk of SMM.
PMID: 38054697
ISSN: 1748-0361
CID: 5591082

Use of Galactagogues to Increase Milk Production Among Breastfeeding Mothers in the United States: A Descriptive Study

Ryan, Rachel A; Hepworth, Allison Doub; Lyndon, Audrey; Bihuniak, Jessica Dauz
BACKGROUND:Perceived insufficient milk is a primary reason for early breastfeeding cessation. Some breastfeeding mothers may use galactagogues (ie, foods, beverages, herbal supplements, and pharmaceuticals) to try to increase milk supply. However, milk production requires frequent and effective milk removal, and there is limited evidence on the safety and efficacy of galactagogues. Additional research on the use of galactagogues is needed to inform breastfeeding support. OBJECTIVE:Describe the prevalence of use and perceived effects of galactagogues and compare galactagogue use by maternal characteristics. DESIGN:Cross-sectional online survey. PARTICIPANTS/SETTING:A convenience sample of 1,294 adult women breastfeeding a singleton child and living in the United States were recruited using paid Facebook advertisements between December 2020 and February 2021. MAIN OUTCOME MEASURES:Self-reported current or previous use of galactagogues and their perceived effects on milk production. STATISTICAL ANALYSES PERFORMED:test of independence and independent t tests compared galactagogue use by select maternal characteristics. RESULTS:More than half of participants (57.5%) reported using any galactagogues, 55.4% reported consuming foods or beverages, and 27.7% reported using herbal supplements. Few participants (1.4%) reported using pharmaceuticals. Participants reported varying effects of specific galactagogues on milk production. Reported galactagogue use was higher among participants who reported first-time breastfeeding (yes: 66.7% vs no: 49.3%; P < 0.001), breastfeeding pumped milk (yes: 63.1% vs no: 50.4%; P < 0.001), formula supplementation (yes: 66.8% vs no: 50.4%; P < 0.001), and perceived insufficient milk (yes: 78.8% vs no: 53.8%; P < 0.001). CONCLUSIONS:Breastfeeding mothers in the United States commonly reported using galactagogues to increase milk production, highlighting the need for research on the safety and efficacy of galactagogues and enhanced breastfeeding support.
PMID: 37236347
ISSN: 2212-2672
CID: 5599102

Emotional safety is patient safety [Editorial]

Lyndon, Audrey; Davis, Dána-Ain; Sharma, Anjana E; Scott, Karen A
PMID: 36732064
ISSN: 2044-5423
CID: 5434822

Examining respect, autonomy, and mistreatment in childbirth in the US: do provider type and place of birth matter?

Niles, P Mimi; Baumont, Monique; Malhotra, Nisha; Stoll, Kathrin; Strauss, Nan; Lyndon, Audrey; Vedam, Saraswathi
BACKGROUND:Analyses of factors that determine quality of perinatal care consistently rely on clinical markers, while failing to assess experiential outcomes. Understanding how model of care and birth setting influence experiences of respect, autonomy, and decision making, is essential for comprehensive assessment of quality. METHODS:We examined responses (n = 1771) to an online cross-sectional national survey capturing experiences of perinatal care in the United States. We used validated patient-oriented measures and scales to assess four domains of experience: (1) decision-making, (2) respect, (3) mistreatment, and (4) time spent during visits. We categorized the provider type and birth setting into three groups: midwife at community birth, midwife at hospital-birth, and physician at hospital-birth. For each group, we used multivariate logistic regression, adjusted for demographic and clinical characteristics, to estimate the odds of experiential outcomes in all the four domains. RESULTS:Compared to those cared for by physicians in hospitals, individuals cared for by midwives in community settings had more than five times the odds of experiencing higher autonomy (aOR: 5.22, 95% CI: 3.65-7.45), higher respect (aOR: 5.39, 95% CI: 3.72-7.82) and lower odds of mistreatment (aOR: 0.16, 95% CI: 0.10-0.26). We found significant differences across birth settings: participants cared for by midwives in the community settings had significantly better experiential outcomes than those in the hospital settings: high- autonomy (aOR: 2.97, 95% CI: 2.66-4.27), respect (aOR: 4.15, 95% CI: 2.81-6.14), mistreatment (aOR: 0.20, 95% CI: 0.11-0.34), time spent (aOR: 8.06, 95% CI: 4.26-15.28). CONCLUSION/CONCLUSIONS:Participants reported better experiential outcomes when cared for by midwives than by physicians. And for those receiving midwifery care, the quality of experiential outcomes was significantly higher in community settings than in hospital settings. Care settings matter and structures of hospital-based care may impair implementation of the person-centered midwifery care model.
PMCID:10152585
PMID: 37127624
ISSN: 1742-4755
CID: 5495672

Linking Patient Safety Climate With Missed Nursing Care in Labor and Delivery Units: Findings From the LaborRNs Survey

Zhong, Jie; Simpson, Kathleen Rice; Spetz, Joanne; Gay, Caryl L; Fletcher, Jason; Landstrom, Gay L; Lyndon, Audrey
OBJECTIVE:This study aimed to explore the association of nurses' perceptions of patient safety climate with missed nursing care in labor and delivery (L&D) units. METHODS:We recruited nurse respondents via email distribution of an electronic survey between February 2018 and July 2019. Hospitals with L&D units were recruited from states with projected availability of 2018 state inpatient data in the United States. Measures included the Safety Attitudes Questionnaire Safety Climate Subscale and the Perinatal Missed Care Survey. We estimated the relationship between safety climate and missed care using Kruskal-Wallis tests and mixed-effects linear regression. RESULTS:The analytic sample included 3429 L&D registered nurses from 253 hospitals (response rate, 35%). A majority of respondents (65.7%) reported a perception of good safety climate in their units, with a mean score of 4.12 (±0.73) out of 5. The mean number of aspects of care occasionally, frequently, or always missed on respondents' units was 11.04 (±6.99) out of 25. χ2 Tests showed that six mostly commonly missed aspects of care (e.g., timely documentation) and three reasons for missed care (communications, material resources, and labor resources) were associated with safety climate groups (P < 0.001). The adjusted mixed-effects model identified a significant association between better nurse-perceived safety climate and less missed care (β = -2.65; 95% confidence interval, -2.97 to -2.34; P < 0.001) after controlling for years of experience and highest nursing education. CONCLUSIONS:Our findings suggest that improving safety climate-for example, through better teamwork and communication-may improve nursing care quality during labor and birth through decreasing missed nursing care. Conversely, it is also possible that strategies to reduce missed care-such as staffing improvements-may improve safety climate.
PMID: 36728161
ISSN: 1549-8425
CID: 5435322

Hospital characteristics associated with nurse staffing during labor and birth: Inequities for the most vulnerable maternity patients

Simpson, Kathleen R; Spetz, Joanne; Gay, Caryl L; Fletcher, Jason; Landstrom, Gay L; Lyndon, Audrey
BACKGROUND:Evidence is limited on nurse staffing in maternity units. PURPOSE/OBJECTIVE:To estimate the relationship between hospital characteristics and adherence with Association of Women's Health, Obstetric and Neonatal Nurses nurse staffing guidelines. METHODS:We enrolled 3,471 registered nurses in a cross-sectional survey and obtained hospital characteristics from the 2018 American Hospital Association Annual Survey. We used mixed-effects linear regression models to estimate associations between hospital characteristics and staffing guideline adherence. FINDINGS/RESULTS:Overall, nurses reported strong adherence to AWHONN staffing guidelines (rated frequently or always met by ≥80% of respondents) in their hospitals. Higher birth volume, having a neonatal intensive care unit, teaching status, and higher percentage of births paid by Medicaid were all associated with lower mean guideline adherence scores. DISCUSSION AND CONCLUSIONS/CONCLUSIONS:Important gaps in staffing were reported more frequently at hospitals serving patients more likely to have medical or obstetric complications, leaving the most vulnerable patients at risk.
PMID: 37004352
ISSN: 1528-3968
CID: 5495602

Neighborhood disinvestment and severe maternal morbidity in the state of California

Mujahid, Mahasin S; Wall-Wieler, Elizabeth; Hailu, Elleni M; Berkowitz, Rachel L; Gao, Xing; Morris, Colleen M; Abrams, Barbara; Lyndon, Audrey; Carmichael, Suzan L
BACKGROUND:Social determinants of health, including neighborhood context, may be a key driver of severe maternal morbidity and its related racial and ethnic inequities; however, investigations remain limited. OBJECTIVE:This study aimed to examine the associations between neighborhood socioeconomic characteristics and severe maternal morbidity, as well as whether the associations between neighborhood socioeconomic characteristics and severe maternal morbidity were modified by race and ethnicity. STUDY DESIGN/METHODS:This study leveraged a California statewide data resource on all hospital births at ≥20 weeks of gestation (1997-2018). Severe maternal morbidity was defined as having at least 1 of 21 diagnoses and procedures (eg, blood transfusion or hysterectomy) as outlined by the Centers for Disease Control and Prevention. Neighborhoods were defined as residential census tracts (n=8022; an average of 1295 births per neighborhood), and the neighborhood deprivation index was a summary measure of 8 census indicators (eg, percentage of poverty, unemployment, and public assistance). Mixed-effects logistic regression models (individuals nested within neighborhoods) were used to compare odds of severe maternal morbidity across quartiles (quartile 1 [the least deprived] to quartile 4 [the most deprived]) of the neighborhood deprivation index before and after adjustments for maternal sociodemographic and pregnancy-related factors and comorbidities. Moreover, cross-product terms were created to determine whether associations were modified by race and ethnicity. RESULTS:Of 10,384,976 births, the prevalence of severe maternal morbidity was 1.2% (N=120,487). In fully adjusted mixed-effects models, the odds of severe maternal morbidity increased with increasing neighborhood deprivation index (odds ratios: quartile 1, reference; quartile 4, 1.23 [95% confidence interval, 1.20-1.26]; quartile 3, 1.13 [95% confidence interval, 1.10-1.16]; quartile 2, 1.06 [95% confidence interval, 1.03-1.08]). The associations were modified by race and ethnicity such that associations (quartile 4 vs quartile 1) were the strongest among individuals in the "other" racial and ethnic category (1.39; 95% confidence interval, 1.03-1.86) and the weakest among Black individuals (1.07; 95% confidence interval, 0.98-1.16). CONCLUSION/CONCLUSIONS:Study findings suggest that neighborhood deprivation contributes to an increased risk of severe maternal morbidity. Future research should examine which aspects of neighborhood environments matter most across racial and ethnic groups.
PMID: 36905984
ISSN: 2589-9333
CID: 5462432

Using medical expenditure panel survey data to explore the relationship between patient-centered medical homes and racial disparities in severe maternal morbidity outcomes

Tucker, Curisa M; Bell, Nathaniel; Corbett, Cynthia F; Lyndon, Audrey; Felder, Tisha M
BACKGROUND/UNASSIGNED:There are persistent racial/ethnic disparities in the occurrence of severe maternal morbidity. Patient-centered medical home care has the potential to address disparities in maternal outcomes. OBJECTIVES/UNASSIGNED:To examine (1) the association between receiving patient-centered medical home care and severe maternal morbidity outcomes and (2) the interaction of race/ethnicity on patient-centered medical home status and severe maternal morbidity. DESIGN/METHODS/UNASSIGNED:Using 2007 to 2016 data from the Medical Expenditures Panel Survey, we conducted a cross-sectional study to estimate the association between receipt of care from a patient-centered medical home and the occurrence of severe maternal morbidity, and racial-specific (White, Black, Asian, Other) relative risks of severe maternal morbidity. Our study used race as a proxy measure for exposure racism. We identified mothers (⩾15 years) who gave birth during the study period. We identified patient-centered medical home qualities using 11 Medical Expenditures Panel Survey questions and severe maternal morbidities using medical claims, and calculated generalized estimating equation models to estimate odds ratios of severe maternal morbidity and 95% confidence intervals. RESULTS/UNASSIGNED: = 0.62) on the severe maternal morbidity outcome. CONCLUSION/UNASSIGNED:While the rate of severe maternal morbidity was similar to US rates, few mothers received care from a patient-centered medical home which may be due to underreporting. Future research should further investigate the potential for patient-centered medical home-based care to reduce odds of severe maternal morbidity across racial/ethnic groups.
PMCID:9887166
PMID: 36660909
ISSN: 1745-5065
CID: 5410772