NYSHealth Foundation Testimony on Maternal Mortality and Morbidity in New York City
The New York City Council Committee on Health, Committee on Hospitals, and Committee on Women and Gender Equity held an oversight hearing on maternal mortality and morbidity in New York City on December 7, 2020. NYSHealth submitted written testimony on the status of maternal health in the City.
December 9, 2020
Distinguished Members of the Committee on Health, Committee on Hospitals, and Committee on Women and Gender Equity:
The New York State Health Foundation (NYSHealth) appreciates the opportunity to submit written testimony on the status of maternal health in New York City. We offer information from our recent research report on severe maternal morbidity in New York to add to the evidence base of racial and ethnic disparities in maternal health outcomes. In addition, we identify policy approaches for consideration to support and encourage the use of midwives and community-based health workers to reduce incidence of severe maternal morbidity, close disparities by race and ethnicity, and accommodate patient choice.
The Status of Maternal Health in New York City
The United States has a higher maternal mortality rate compared to other peer developed nations.1, 2 Unfortunately, maternal death is considered the “tip of the iceberg” of an even larger body of adverse maternal events impacting women.3, 4 Prior research has found that for every maternal death, there are up to 100 occurrences of severe maternal morbidity (SMM).5 SMM refers to outcomes during labor and delivery that result in adverse short- or long-term consequences to a woman’s health.6 These outcomes may be life-threatening and require the need for lifesaving procedures, such as a blood transfusion or ventilation.7
New York State has historically had higher rates of SMM than the rest of the nation. The most recent years of nationwide data show that New York State ranked in highest quartile of state SMM rates.8 Prior research has documented the high rates of SMM and racial and ethnic disparities in New York City specifically. 9, 10,11 This is particularly concerning given that, in 2018, New York City accounted for approximately half (49%) of all deliveries in the State, including more than half of all Black and Hispanic deliveries. There are significant disparities in SMM by race and ethnicity in New York City, even after controlling for differences in health status, insurance type, sociodemographic characteristics, education, prenatal care, and socioeconomic status.12, 13
NYSHealth’s Work to Improve Maternal Health
NYSHealth is a private, independent foundation that works to improve the health of all New Yorkers, especially the most vulnerable. Our grantmaking and research has provided us with experience in and knowledge of the disparities in maternal health across New York State. In particular, through our Empowering Health Care Consumers program, we have supported work to expand access to transparent information about maternal health care quality and outcomes.14
NYSHealth has recently funded multiple projects to enable New Yorkers to make informed and higher-value decisions about maternity care. This includes the development of an online tool that allows expectant mothers to compare local providers in the New York City area based on quality measures and other factors that affect maternity and newborn care.15 In addition, the Foundation is supporting an effort by one of the largest unions in the State to develop a high-value maternity care network for its expectant parents, who are predominantly lower-wage union workers and women of color.16, 17
New Research on Severe Maternal Morbidity in New York City
At this critical juncture, NYSHealth would like to provide the Committees with new research that sheds light on the stark racial and ethnic disparities in severe maternal morbidity in New York City. This analysis can support the City in its continued efforts to design programs and target resources. Below are key findings from a 2020 NYSHealth analysis of SMM, using 2011–2018 inpatient hospital admissions associated with deliveries.
- 3,311 deliveries in New York City in 2018 were associated with an SMM event, out of the 102,268 inpatient hospital admissions associated with deliveries analyzed.18 This translates to an overall SMM rate of approximately 324 out of every 10,000 deliveries (or 3.2%) (see Figure 1). This was higher than the overall New York State rate (2.7 %).
- In 2018, New York City had the highest rate of SMM in the State, with an SMM rate more than three-and-a-half times larger than the region with the lowest rate (324 per 10,000 deliveries in New York City, compared to 90 per 10,000 in the Finger Lakes) (see Figure 2).
- Disparities in SMM by race and ethnicity persisted in New York City from 2011 through 2018 (see Figure 3). In 2018, the SMM rate for Black women was 506 per 10,000 deliveries, amounting to 2.3x the rate for white women.19 The rate for Hispanic women was approximately 1.7x the rate for white women; the rate for Asian women was approximately 1.3x the rate for white women (362 and 274 per 10,000, respectively, compared to 216 per 10,000). For Black and Hispanic women, these are similar disparities as in 2011 (2.6x for Black women and 1.7x for Hispanic women).
- Racial and ethnic disparities were present both for populations covered by Medicaid and those covered by private insurance plans. Substantial racial and ethnic disparities were also present across both vaginal and cesarean deliveries.
- The majority of SMM events were related to blood transfusions (see Figure 4). Blood transfusions are a proxy for identifying hemorrhage, a form of SMM, but can be an imperfect indicator of SMM. The recent increase in blood transfusion may reflect increased quality improvement efforts in New York to mitigate maternal hemorrhage. However, there remain racial and ethnic disparities in SMM cases with and without blood transfusions.
For more details about this data, please see our full report, available here: https://nyshealthfoundation.org/wp-content/uploads/2020/08/severe-maternal-morbidity.pdf.
Expanding the Role of Midwives and Community-Based Health Workers
Several important provisions have been implemented to reduce SMM and address racial and ethnic disparities in recent years at both the City and State levels. Our full report discusses recent efforts to increase quality improvement, improve data collection and monitoring, combat implicit bias, and facilitate access to community-based health workers. Recognizing that some of the causes of SMM, such as implicit racial bias, have been ingrained into the societal and health care system culture for decades, solutions must draw from all these domains and work in tandem. For example, while the City’s Maternal Mortality and Morbidity Review Committee identifies clinical trends by conducting case reviews of every maternal death in the City, the City’s Maternal Hospital Quality Improvement Network can use these data to provide hospital-specific recommendations to reduce disparities in preventable SMM. A coordinated, sustained, and aggressive effort will be required to permanently reduce SMM in New York City...