Elizabeth Howell
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Disparities in Severe Maternal Morbidity and Mortality: Where Do We Go From
Here?
Elizabeth Howell MD, MPP Director, Blavatnik Family Women’s Health Research Institute
Professor & Vice Chair of ResearchObstetrics, Gynecology, and Reproductive Science
Icahn School of Medicine at Mount Sinai
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Presenter Disclosures
I have no personal financial relationships with commercial interests relevant to this presentation
Elizabeth Howell, MD, MPP
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Objectives
• Describe racial and ethnic disparities in severe maternal mortality and morbidity
• Understand how delivery care may impact disparities in severe maternal morbidity and mortality
• Describe steps that institutions can take to address racial and ethnic disparities in severe maternal morbidity and mortality
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Elizabeth Howell
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Maternal Healthcare Crisis
New York Times
ProPublica and NPR. Accessed 9/28/18. https://www.npr.org/2017/05/12/528098789/u-s-has-the-worst-rate-of-maternal-deaths-in-the-developed-worldBased on data from "Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015," The Lancet. Only data for 1990, 2000 and 2015 was made available in the journal. Source: The Lancet Credit: Rob Weychert/ProPublica
US Maternal Mortality Rises while it Declines Elsewhere
Disparities in Maternal Mortality
• Minorities represent half of US births and racial/ethnic minorities suffer higher maternal mortality rates
• Black women 3 to 4 times more likely to die than white women – largest disparity among population perinatal health measures
• Native Americans, some Asians, some Latinas also have elevated rates
CDC Pregnancy Mortality Surveillance System at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html
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Elizabeth Howell
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United States Pregnancy-related Mortality by Race, Ethnicity, Nativity 2000-2006
10.3
39.9
10.3 10.98.4
34.1
12.3 11.7
0
5
10
15
20
25
30
35
40
45
White Black Hispanic Asian/ PacificIslander
US Born
Not US Born
Dea
ths/
100,
00 li
ve b
irths
Creanga, Obstet Gynecol. 2012 Aug;120(2 Pt 1):261-8. 7
Pregnancy-Related Mortality Ratios by Race-Ethnicity, 2011-2013
43.5
14.4 12.7 11.0
0
5
10
15
20
25
30
35
40
45
50
Non-HispanicBlack
Non-HispanicWhite
Hispanic Other Race-Ethnicities
Pre
gnan
cy-r
elat
ed m
orta
lity
ratio
per
10
0,00
0 liv
e bi
rths
Creanga Obstet Gynecol. 2017;130(2),366–373.
Creanga. J of Women’s Hlth; 2014 Jan;23(1):3-9.
CDC US Pregnancy-related Mortality by Race
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Elizabeth Howell
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Maternal Mortality (per 100,000)
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Moaddab.A.Health Care Disparity and State-Specific Pregnancy-Related Mortality in the United States, 2005-2014. ObstetGynecol 2018;131:707–12.
Disparities More Pronounced in New York City
• Blacks 12 times more likely to die– Widening of gap since 2001-2005– Increased gap driven by 45% decreased
mortality among whites
• Asian/Pacific Islanders 4x as likely to die• Latinas 3x as likely to die
New York City Department of Health and Mental Hygiene (2015).Pregnancy Associated Mortality in New York City, 2006-2010.
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New York City Department of Health and Mental Hygiene (2015).Pregnancy Associated Mortality in New York City, 2006-2010. 12
Elizabeth Howell
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New York City Department of Health and Mental Hygiene (2015). Pregnancy Associated Mortality in New York City, 2006-2010.
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Severe Maternal Morbidity (SMM)
• For every maternal death, 100 women experience severe maternal morbidity
• Life-threatening diagnosis or life-saving procedure– organ failure (e.g. renal, liver), shock, amniotic
embolism, eclampsia, septicemia, cardiac events– ventilation, transfusion, hysterectomy
• Significant racial/ethnic disparities exist
Callaghan. Obstet Gynecol 2012;120:1029-36.
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Elizabeth Howell
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New York City Department of Health and Mental Hygiene (2016).Severe Maternal Morbidity in New York City, 2008–2012. New York, NY.
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New York City Department of Health and Mental Hygiene (2016).Severe Maternal Morbidity in New York City, 2008–2012. New York, NY.
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How Did We Get Here?
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Elizabeth Howell
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Patient Factors - Socio-demographics: age,
education, poverty, insurance, marital status, employment, language, literacy
- Knowledge, beliefs, healthbehaviors
- Psychosocial: stress, self-efficacy, social support
Outcomes Severe
Maternal Morbidity
& Mortality
Preconception Care
Antenatal Care
Delivery & Hospital
Care
Postpartum Care
Figure 1: Pathways to Racial and Ethnic Disparities in Severe Maternal Morbidity & Mortality
Rac
e/ E
thn
icit
y
Community/ Neighborhood- Community, social network- Neighborhood: crime,
poverty, built environment, housing
He
alt
h s
tatu
s:
co
mo
rbid
itie
s (
e.g
. H
TN
, D
M,
ob
es
ity,
de
pre
ss
ion
);
Pre
gn
an
cy
co
mp
lica
tio
ns
Provider Factors- Knowledge, experience,
implicit bias, cultural competence, communi-cation
System Factors- Access to high quality care,
transportation, structural racism, policy
Howell EA. Clin Obstet Gynecol. 2018 Jun;61(2):387-399
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Patient Factors - Socio-demographics: age,
education, poverty, insurance, marital status, employment, language, literacy
- Knowledge, beliefs, healthbehaviors
- Psychosocial: stress, self-efficacy, social support
Outcomes Severe
Maternal Morbidity
& Mortality
Preconception Care
Antenatal Care
Delivery & Hospital
Care
Postpartum Care
Figure 1: Pathways to Racial and Ethnic Disparities in Severe Maternal Morbidity & Mortality
Rac
e/ E
thn
icit
y
Community/ Neighborhood- Community, social network- Neighborhood: crime,
poverty, built environment, housing
He
alt
h s
tatu
s:
co
mo
rbid
itie
s (
e.g
. H
TN
, D
M,
ob
es
ity,
de
pre
ss
ion
);
Pre
gn
an
cy
co
mp
lica
tio
ns
Provider Factors- Knowledge, experience,
implicit bias, cultural competence, communi-cation
System Factors- Access to high quality care,
transportation, structural racism, policy
Howell EA. Clin Obstet Gynecol. 2018 Jun;61(2):387-399
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Hospital Quality and Disparities
• Sixty percent of severe events / maternal deaths preventable
• Hospital quality important contributing factor• Site of care receiving increasing attention as
mechanism for disparities • Growing body of research suggests
racial/ethnic women deliver in lower quality hospitals
Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal mortality review committees. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs. Howell. Am J Obstet Gynecol. 2016 Jan;214(1):122.e1-e9. Creanga AJOG 2014 21
Elizabeth Howell
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Research on Delivery Hospital and US Disparities
• In US, 75% of all black women deliver in a quarter of all hospitals vs. 18% of white women
• Hospitals that disproportionately care for black women– have higher risk adjusted SMM rates for both
blacks and whites
– perform worse than other hospitals on delivery-related indicators
Howell. Am J Obstet Gynecol. 2016 Jan;214(1):122.e1-e9; Creanga AJOG 2014 Dec;211(6):647.e1-16.
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Methods
• Nationwide Inpatient Sample (2010 – 2011)
• Identified severe maternal morbidity (SMM)
• Ranked hospitals by proportion of black women who delivered in the hospital:– High (top 5%) - Medium (5-25%)
– Low (remainder)
• Analyzed risks of SMM for black and white women by hospital category using logistic regression adjusting for patient comorbidities, hospital factors, and patient clustering
Distribution of Black and White Deliveries at Hospitals in US
24%
50%
26%
2%
16%
82%
0%
20%
40%
60%
80%
100%
High Medium LowCu
mu
lati
ve P
erce
nta
ge
of
Del
iver
ies
Black White(N=279) (N=1106) (N=4102)
Howell. Am J Obstet Gynecol. 2016 Jan;214(1):122.e1-e924
Elizabeth Howell
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Distribution of Black and White Deliveries at Hospitals in US
24%
50%
26%
2%
16%
82%
0%
20%
40%
60%
80%
100%
High Medium LowCu
mu
lati
ve P
erce
nta
ge
of
Del
iver
ies
Black White(N=279) (N=1106) (N=4102)
Much higher rates of severe maternal morbidity for black and white moms
Howell. Am J Obstet Gynecol. 2016 Jan;214(1):122.e1-e925
Implications
• Differential access to higher quality hospitals may partially explain excess morbidity among black women
• Research needed to investigate clinical and hospital factors that contribute to disparities and severe morbidity
• Specific research needed to identify attributes of high performing hospitals
Next Steps in Our ResearchNew York City Hospitals*
• Mixed methods study to investigate hospital quality and disparities in SMM
• Examine hospital risk-adjusted SMM and racial/ethnic distribution of deliveries
• Conduct qualitative interviews to examine safety culture, QI, and other factors
• Conduct focus groups to explore receipt of high quality care
*Funded by NIH #R01MD007651Howell Am J Obstet Gynecol. 2016 Aug;215(2):143-52; Howell. Obstet Gynecol. 2017 Feb;129(2):285-294.
Elizabeth Howell
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Phase 1 Methods
• Vital Statistics linked with SPARCS for all New York City deliveries (2011-2013)
• CDC algorithm to identify severe morbidity
• Mixed-effects logistic regression to calculate risk-standardized severe maternal morbidity rates (SSMMR) for each hospital
• Ranked hospitals based on SSMMR
• Assessed black-white differences and Hispanic-white differences in delivery location
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Severe Maternal Morbidity Rates in New York City
4.2%
2.7%
1.5%
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
4.5%
Black Latina White
Black
Latina
White
Howell Am J Obstet Gynecol. 2016 Aug;215(2):143-52; Howell. Obstet Gynecol. 2017 Feb;129(2):285-294.
0%
1%
2%
3%
4%
5%
6%
7%
Ris
k st
and
ard
ized
m
ater
nal
mo
rbid
ity
(%)
RSSMM
Hospitals ranked from lowest to highest Observed rates: 0.6% to 11.5%; Risk standardized rates: 0.8% to 5.7%
Hospital Rankings
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Elizabeth Howell
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0%
1%
2%
3%
4%
5%
6%
7%
Ris
k st
and
ard
ized
m
ater
nal
mo
rbid
ity
(%)
RSSMM
Low Morbidity
Medium Morbidity
HighMorbidity
Hospitals ranked from lowest to highest morbidity Observed rates: 0.6% to 11.5%; Risk standardized rates: 0.8% to 5.7%
Hospital Rankings
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Deliveries by Race / Ethnicity and Risk-standardized Hospital Morbidity
Hospital Group by RSSMM*
Low Medium High
Black (%) 23 39 37
White (%) 65 17 18
Hispanic (%) 33 38 29
Howell Am J Obstet Gynecol. 2016 Aug;215(2):143-52; Howell. Obstet Gynecol. 2017 Feb;129(2):285-294
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Deliveries by Race /Ethnicity and Risk-standardized Hospital Morbidity
Hospital Group by RSSMM*
Low Medium High
Black (%) 23 39 37
White (%) 65 17 18
Hispanic (%) 33 38 29
Howell Am J Obstet Gynecol. 2016 Aug;215(2):143-52; Howell. Obstet Gynecol. 2017 Feb;129(2):285-294
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Elizabeth Howell
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Deliveries by Race / Ethnicity and Risk-standardized Hospital Morbidity
Hospital Group by RSSMM*
Low Medium High
Black (%) 23 39 37
White (%) 65 17 18
Hispanic (%) 33 38 29
Howell Am J Obstet Gynecol. 2016 Aug;215(2):143-52; Howell. Obstet Gynecol. 2017 Feb;129(2):285-294
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Thought Experiment
• Differences in hospital of delivery may account for up to:– 48% of the black-white disparity
– 37% of the Hispanic-white disparity
Howell Am J Obstet Gynecol. 2016 Aug;215(2):143-52; Howell. ObstetGynecol. 2017 Feb;129(2):285-294
Summary
• Wide variation in risk-standardized maternal morbidity among NYC hospitals
• Higher rates of severe maternal morbidity among blacks and Latinas partially due to differences in delivery location
• Delivery location partially explains morbidity disparities
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Elizabeth Howell
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Next Steps
• Currently conducting hospital qualitative interviews
• Focus groups to explore patient barriers to receipt of high quality care
• Dissemination efforts to increase uptake of best practices
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Qualitative Interview Topics• Structural Characteristics (e.g. staffing,
credentialing, capacity, resources, environment)
• Organization Factors (culture, leadership, feedback, communication, promotion of evidence-based practices, progress in QI and disparities reduction)
• L&D (use of evidence-based practices, teamwork, culture, errors, drills)
Types of Interviewees
• Directors of L&D
• Chairs of Ob/Gyn
• Nurse managers for L&D
• Front line nurses
• Chief Medical Officer or designee
• Quality leads in obstetrics
Elizabeth Howell
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Where Do We Go From Here?Levers to Reduce Disparities
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Outcomes Severe
Maternal Morbidity &
Mortality
Preconception Care
Antenatal Care
Delivery & Hospital Care
Postpartum Care
Levers to Reduce Racial and Ethnic Disparities in Severe Maternal Morbidity & Mortality
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Outcomes Severe
Maternal Morbidity &
Mortality
Preconception Care
Antenatal Care
Delivery & Hospital Care
Postpartum Care
Levers to Reduce Racial and Ethnic Disparities in Severe Maternal Morbidity & Mortality
Promote contraceptionOptimize preconception health
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Elizabeth Howell
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Outcomes Severe
Maternal Morbidity &
Mortality
Preconception Care
Antenatal Care
Delivery & Hospital Care
Postpartum Care
Levers to Reduce Racial and Ethnic Disparities in Severe Maternal Morbidity & Mortality
Promote contraceptionOptimize preconception health
New models –Centering, Medical Homes, enhanced models for high risk women
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Outcomes Severe
Maternal Morbidity &
Mortality
Preconception Care
Antenatal Care
Delivery & Hospital Care
Postpartum Care
Levers to Reduce Racial and Ethnic Disparities in Severe Maternal Morbidity & Mortality
Promote contraceptionOptimize preconception health
New models –Centering, Medical Homes, enhanced models for high risk women
QI, standardization, bundles, team training, simulations, reviews, protocols, disparities dashboard
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Outcomes Severe
Maternal Morbidity &
Mortality
Preconception Care
Antenatal Care
Delivery & Hospital Care
Postpartum Care
Levers to Reduce Racial and Ethnic Disparities in Severe Maternal Morbidity & Mortality
Promote contraceptionOptimize preconception health
New models –Centering, Medical Homes, enhanced models for high risk women
New models –Patient navigatorsCase management
QI, standardization, bundles, team training, simulations, reviews, protocols, disparities dashboard
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Elizabeth Howell
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https://www.vox.com/identities/2018/1/11/16879984/serena-williams-childbirth-scare-black-women
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ProPublica and NPR story - Nothing Protects Black Women From Dying in Pregnancy and Childbirth
Dec 7, 2017
“In the more than 200 stories of African-American mothers that ProPublicaand NPR have collected over the past year, the feeling of being devalued and disrespected by medical providers was a constant theme. The young Florida mother-to-be whose breathing problems were blamed on obesity when in fact her lungs were filling with fluid and her heart was failing. The Arizona mother whose anesthesiologist assumed she smoked marijuana because of the way she did her hair. The Chicago-area businesswoman with a high-risk pregnancy who was so upset at her doctor’s attitude that she changed OB-GYNs in her seventh month, only to suffer a fatal postpartum stroke.
Over and over, black women told of medical providers who equated being African American with being poor, uneducated, noncompliant and unworthy. “Sometimes you just know in your bones when someone feels contempt for you based on your race,” said one Brooklyn woman who took to bringing her white husband or in-laws to every prenatal visit.” 47
Outcomes Severe
Maternal Morbidity &
Mortality
Preconception Care
Antenatal Care
Delivery & Hospital Care
Postpartum Care
Levers to Reduce Racial and Ethnic Disparities in Severe Maternal Morbidity & Mortality
Promote contraceptionOptimize preconception health
New models –Centering, Medical Homes, enhanced models for high risk women
New models –Patient navigatorsCase management
QI, standardization, bundles, team training, simulations, reviews, protocols, disparities dashboard
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Elizabeth Howell
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Slide 49
Friday, November 4, 2016
12:30 p.m. EasternDial In: 888.863.0985
Conference ID: 49389917
Alliance for Innovation on Maternal Health
• Cooperative agreement between ACOG and Maternal Child Health Bureau
• National data-driven maternal safety and quality improvement initiative
• Patient safety bundles to standardize delivery care
• Reaches over one-half US births by partnering with states, DOH, health systems
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Alliance for Innovation on Maternal Health: Focus on Disparities
• One of the first professional bodies to address disparities
• Unique perspective - addressing disparities under a patient safety umbrella
• Raises awareness among health systems, departments of health, hospitals, and clinicians who care for pregnant and postpartum women
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Elizabeth Howell
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Reduction of Peripartum Racial Disparities Patient Safety Bundle Development
Multidisciplinary Team– William Grobman, MD, FACOG
– Elizabeth Howell, MD, MPP, FACOG
– Haywood Brown, MD
– Jessica Brumley, PhD, CNM
– Allison Bryant, MD, MPH
– Aaron Caughey, MD, PhD
– Andria Cornell, MSPH
– Jacqueline Grant, MD, MPH, MPA
– Kimberly Gregory, MD, MPH
– Sue Gullo, RN, BSN, MS
– Pandora Hardtman, CNM
– Jill Mhyre, MD
– Katy Kozhimannil, PhD, MPA
– Jill Mhyre,MD
– Geeta Sehgal, DO
– Paloma Toledo, MD, MPH
– Robyn D’Oria, MA, RNC, APN
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Bundle Development
• Review of literature
– Disparities frameworks
– Drivers of disparities and relative contributions• Examples from all of medicine
– Effective interventions to reduce disparities
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Disparities
Cultural competent
communication
Literacy
Language
Fragmentation
Bias
Comorbidity
Inter-institutional differences
Education
Poverty
Institutional racism
Environment
Disparities Bundle Framework
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Elizabeth Howell
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Disparities Bundle Themes
• Care fragmentation– Importance throughout reproductive life
• Communication– Patient education (culturally competent)
– Shared decision-making
• Systemic racism– Implicit bias
• Lack of measurement and benchmarking– Disparity dashboard
– Inter-hospital differences 55
Four Domains of Patient Safety Bundles
• Readiness
• Recognition
• Response
• Reporting/Systems Learning
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Four Domains of Patient Safety Bundles
• Readiness
• Recognition
• Response
• Reporting/Systems Learning
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Elizabeth Howell
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Key References
Reduction of Peripartum Racial/Ethnic Disparities http://safehealthcareforeverywoman.org/patient-safety-bundles/reduction-of-peripartum-racialethnic-disparities/
Consensus StatementHowell EA*, Brown H, Brumley J, Bryant A, Caughey A, Cornell A, Grant JH, Gregory KD, Gullo SM, Kozhimannil KB, Mhyre JM, Toledo P, D’Oria R, Ngoh, M, Grobman WA. Reduction of Peripartum Racial and Ethnic Disparities: A Conceptual Framework and Maternal Safety Consensus Bundle. - Obstet Gynecol. 2018 May;131(5):770-782- J Midwifery Womens Health. 2018 Apr 23. - J Obstet Gynecol Neonatal Nurs. 2018 May;47(3):275-289
THANK YOU
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