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Health Disparities

The maternal death tragedy: Facts come into better focus

African-American women have a higher rate of maternal mortality than other women in Georgia. (This is a stock photo)

African-American women have a higher rate of maternal mortality.   (This is a stock photo)

“Maternal mortality” is a chilling phrase. And it’s a term that has haunted Georgia public health and medical officials for years.

Also known as death related to pregnancy, maternal mortality is defined as the death of a woman while she is pregnant or within one year after the end of her pregnancy, from any cause related to or aggravated by the pregnancy or its management.

A few years ago, a report surfaced that Georgia had the highest rate of maternal mortality in the nation. It came as jarring news.

The state was reported to have reached 28.7 maternal deaths per 100,000 live births in 2011, up from an average of 20.2 in the period 2001 to 2006.

The Georgia General Assembly, alarmed by those numbers, passed a law last year that laid the foundation for a committee to review such deaths.

Dr. Michael Lindsay

Dr. Michael Lindsay

Recently the committee produced its first report, analyzing cases from 2012.

Surprisingly, the panel determined that the original shocking statistics were not completely reliable. At the same time, the panel found some key trends in the Georgia deaths studied.

First the numbers: The maternal mortality panel leaders discovered that some Georgia deaths listed as related to or associated with pregnancy did not belong in those categories. The deaths had been wrongly classified.

“We found a lot of patients [who had died] had not been pregnant within a year,’’ Dr. Michael Lindsay, an Atlanta ob/gyn and chairman of the review panel, said recently.

The committee concluded that there’s no way to say whether Georgia – or some other state – has the worst record on maternal mortality. Because of the uncertainty involved with available statistics, it’s impossible to compare states on maternal mortality. “Only about 25 states do a formal maternal mortality review,’’  said Lindsay, associate professor in the division of gynecology and obstetrics at the Emory School of Medicine.

But the Peach State can’t take too much satisfaction in shedding that infamous No. 1 label. Lindsay said the panel also concluded that Georgia, in fact, has “among the highest rates”  of maternal mortality.


Breaking down the numbers


The panel’s report identified 85 maternal deaths. Of those, 25 were classified as “pregnancy-related.” The other 60 occurred while the woman was pregnant or within one year of the end of the pregnancy, but were not necessarily related to the pregnancy. The panel called these deaths “pregnancy-associated.”

Other findings included:

** Sixty percent of the maternal deaths were of women 29 or younger

** African-Americans were the predominant racial/ethnic group among the cases reviewed

** Obesity was a compounding factor in many cases

pregnant-mother-sonThe mortality report noted that chronic medical conditions increase risks during pregnancy. Pregnant or postpartum women often lack access to mental health services, and lack of access to care was cited as a potential problem.

The maternal mortality review effort came as a collaboration with the CDC, the Georgia Department of Public Health and the Georgia OBGyn Society.

Sen. Dean Burke (R-Bainbridge), a physician who sponsored legislation to create the state review panel, said Thursday that the obesity factor “surprised me the most – how much influence it has on maternal mortality.”

Of the deaths from pregnancy-related reasons, the most common cause was hemorrhage, followed by cardiac disorders, embolism and seizure disorders. Among the deaths listed as pregnancy-associated, the leading causes were motor vehicle crashes, homicide and suicide.

“The results of our first year of work provided some excellent information on efforts that can be made in the medical community to decrease maternal deaths,’’ said Pat Cota, executive director of the Georgia OBGyn Society. “We have already begun education campaigns in a number of areas.”

“One of the key findings,” Cota added, “is that women need to be healthier before they become pregnant, through efforts such as weight management and hypertension control, so the pregnancy does not put undue stress on their bodies.”

Lindsay noted that the South generally has a higher rate of maternal mortality, and that minorities account for a much higher percentages of these deaths than do whites.


Much more to learn


The Georgia data are preliminary in terms of making recommendations, Lindsay cautioned.

“Our goal is to make the information widely available,’’ he said. “We need to recognize . . . [maternal mortality] as a problem. It’s a matter of educating health care providers and the lay public that this is a public health problem.”

Sen. Burke, an ob/gyn who is now a Bainbridge hospital’s chief medical officer, pointed out that many hospitals in rural areas of Georgia have shut down their obstetrical services due to financial losses. “We’ve got to stabilize that and stop the deterioration in the number of [obstetrics] units and providers,’’ he said.

230px-PregnantWomanHigher pay will help. The state budget, Burke noted, has increased reimbursements for ob/gyns under the Medicaid program, which covers the majority of childbirths in the state.

Burke said he believes physicians will give a lot of consideration to the report’s findings. “Doctors respond to data very well. It’s very critical that the committee continue to do the work it’s doing.”

The Department of  Public Health, meanwhile, is collaborating with the Association of Women’s Health, Obstetric and Neonatal Nurses and Merck for Mothers to improve clinical practice and reduce errors related to postpartum hemorrhage, the leading cause of maternal death.

Public Health has joined other states to strengthen and enhance state maternal mortality surveillance systems. The agency has distributed maternal mortality education materials to ob/gyns and hospitals throughout the state, along with information about the use of antidepressant medications in pregnancy.

Georgia birth certificates have been adjusted to reflect information about previous poor pregnancy outcomes and risk factors during the pregnancy being recorded, among other data. And DPH is also reviewing changes to Georgia death certificates to more accurately identify maternal deaths.

The maternal mortality committee is already looking at possible pregnancy-related deaths from 2013.

“Our goal,” said Lindsay, “is to hopefully uncover information that will lead to lower mortality.”




Researcher looks at roots of health disparities (video)

Kinesiology professor Kevin McCully oversees his graduate assistant, Melissa Erickson, as she prepares to measure graduate assistant Zoe Young's blood flow.

Kinesiology professor Kevin McCully oversees his graduate assistant, Melissa Erickson, as she prepares to measure graduate assistant Zoe Young's blood flow. They are part of research on health disparities that is being led by Dr. Jonathan Murrow. Photo by Chelsea Toledo

A cardiologist has returned to his home turf to study a disease that exacts a major toll in Georgia, especially for blacks.

Cardiovascular disease causes 20 percent of all deaths in Georgia, but it’s responsible for 30 percent of deaths of black Georgians, according to the Georgia Department of Public Health.

More than twice as many blacks as whites are hospitalized in Georgia for high blood pressure, which can lead to heart attack and stroke. Whites live, on average, six and a half years longer than blacks in Georgia, where heart disease remains the leading cause of death.

Those disparities motivated Dr. Jonathan Murrow to return to northeast Georgia to do research that could improve health in the state. Since graduating from Emory University School of Medicine in 2001, the native of Farmington – just south of Athens – has held cardiology fellowships at Johns Hopkins University and Emory and now teaches at the new medical campus in Athens.

He is the first faculty member to begin research at the year-old medical campus, a partnership between the University of Georgia and Georgia Health Sciences University.

”My wife and I always thought that Athens was great,” Murrow said, “but that it would be perfect if they just had a medical school here. And it turns out, right as we were finishing our training, they opened a medical school in Athens. So it was a cosmic alignment of the stars.”

The medical school in Athens gives doctors such as Murrow access to the university’s array of academic departments, where innovative research partnerships can form.

“The advantage of having the medical campus in Athens was the opportunity for collaboration with many of the colleges at UGA in which faculty concerned with health disparities reside,” said Barbara Schuster, dean of the Georgia Health Sciences University/University of Georgia Medical Partnership.

Murrow aims to learn more about why conditions such as high blood pressure weigh more heavily on the African-American population and the poor. And he has sought out people on campus looking to answer that same question.

“In clinical practice, one question that comes up is why are some groups of people disproportionately affected by diseases, and vascular diseases in particular,” Murrow said.

Murrow’s research partners are equally interested in understanding why African-Americans face a greater risk of high blood pressure and other cardiovascular diseases.

“My father and my mother actually both had high blood pressure. They’re both deceased now,” said Deborah Elder, an African-American who is assistant professor of pharmacy and biomedical sciences at UGA.

“And I myself have been taking blood pressure medicine since the age of 36,” she said. “The doctors say, ‘You don’t really have a weight problem, you eat well, you exercise, but you have hypertension and it goes back to your parents.’ I mean, it’s a hereditary thing. So I think these types of research projects will help us get a better grip on that.”

Does anxiety affect blood flow?

Elder, along with kinesiology professor Kevin McCully, is collaborating with Murrow to determine whether mental stress is to blame for the disproportionate effect experienced by African-Americans when it comes to vascular diseases like high blood pressure.

So far, they’ve been able to confirm that mental stress alone can increase blood flow, an indicator of abnormality and a possible precursor to vascular conditions such as hypertension and peripheral arterial disease.

Now, using an IV drug, the researchers will alter the amount of nitric oxide – which causes blood vessels to relax – in the study volunteers’ bloodstreams to see if that affects blood flow.

The aim is to zero in on the relationship between stress and blood flow.

As Athens-Clarke County has a high poverty level, and 27 percent of its residents are black, the researchers hope their findings will improve health on the home front.

“Unfortunately, lower socioeconomic status is often associated with not eating right,’’ McCully said. “Even higher stress is associated with a less secure economic environment.”

The researchers hope to shed light on the intricate inner workings — or mechanisms — causing some people to be sicker than others.

“I think the first question in this type of study is to understand the mechanism, and from that, to identify the intervention,” Murrow said. “That doesn’t necessarily mean it’s a pharmaceutical or drug intervention or lifestyle intervention, but without knowing the mechanism, it makes it tougher to target the problem in a meaningful way.”

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AIDS map adds Georgia data, much of it grim

Georgia Aids Rates by County

These demographic maps of Georgia show the HIV prevalence rates in the state among black and white residents.

An interactive online map that gives a stark portrait of HIV and AIDS across the country now includes new data about the disease in Georgia.

Last week, the AIDSVu map ( added information on the age, sex and race of people with HIV in Georgia. HIV is the virus that causes AIDS.

The map shows the much higher rates of HIV infection among blacks than whites in the state. It also shows how Georgia and the rest of the Southeast have been particularly devastated by the disease.

Overall, the AIDSVu map breaks down prevalence rates by state and county in a way that laypeople can understand, say researchers at Emory University’s Rollins School of Public Health, who created the site.

“It gives us a chance to look at the geography of HIV in the U.S.,’’ said Patrick Sullivan, associate professor of epidemiology at Emory.

AIDSVu was launched in June, the 30-year anniversary of the first recognition of the AIDS epidemic by the public health community.

The CDC estimates that more than 1 million Americans are living with HIV, and that 56,000 people are newly infected each year. But an estimated one in five people with HIV do not know their status because they have not been tested and diagnosed.

Emory worked with the CDC and with state departments of public health to gather data for the map. AIDSVu also gives information on where to get tested for HIV.

Sullivan noted that many Americans believe the HIV/AIDS epidemic has faded in recent years. “The map is a way to remind us that it’s still a problem, and particularly a problem in the Southeast.’’

Besides having disproportionate rates of infection, African-Americans in Georgia have much higher death rates from the disease, Dr. George Rust, director of the National Center for Primary Care at Morehouse School of Medicine in Atlanta, said Monday in a separate interview.

Blacks also have more difficulty in getting lifesaving drug treatment, he said.

Racial disparities in Georgia exist on many other diseases and health problems, including childhood asthma, infant mortality, and cardiovascular disease. “Poverty is a clear driver’’ of these gaps, Rust added.

Feds help state fund HIV fight

In other recent news related to HIV in Georgia, the federal government has given $3 million to the state for a program to improve access to medications for people living with HIV or AIDS. Here’s an Athens Banner-Herald article about the funding.

The new money won’t be enough to end the waiting list for these drugs, consumer advocates say.

There are 1,763 people on Georgia’s AIDS Drug Assistance Program (ADAP) waiting list. The $3 million is projected to bring about 277 people off the list, said Jeff Graham of Georgia Equality, which runs an advocacy network for people with HIV. That would still leave roughly 1,500 on the list.

“I’m definitely pleased that Georgia was able to receive the maximum amount available for any one state, [but] it’s still far short of what is needed to eliminate the current waiting list,’’ Graham said Monday.

A large majority of those on the ADAP waiting list are being helped by patient assistance programs run by drug manufacturers, but that corporate help is not a long-term solution, Graham said recently.

Georgia scores low on child health report

The Commonwealth Fund's Child Health Scorecard.

The Commonwealth Fund's Child Health Scorecard. The lowest-performing states (by quartile), such as Georgia, are dark blue. Medium blue states are slightly better, and light blue states better still. The best-performing states are in white.

High rates of obesity and infant mortality helped sink Georgia to the low end of a new state-by-state scorecard on children’s health.

Georgia ranked 43rd for child health among the states and the District of Columbia in the 2011 report card developed by the Commonwealth Fund. It was released Feb. 2.

The report analyzed 20 indicators of children’s health status in four areas: health care access and affordability; prevention and treatment; potential to lead healthy lives; and an “equity” measure based on income and racial and ethnic disparities.

The scorecard showed that the Southeast and Southwest generally ranked in the bottom quarter of states. Exceptions were Alabama, Tennessee, North Carolina and South Carolina.

The states in the southern regions “all have chronic issues of low incomes and poverty and health disparities,’’ said Kathleen Adams, an Emory University health policy professor. Rural areas of these states also have problems with access to medical care, she added.

The health indicators that affected Georgia’s placement included:

Georgia ranked 42nd in its infant mortality rate and 49th in the percentage of children ages 10 to 17 who are overweight or obese.

The state was 48th in the percentage of children needing mental health treatment or counseling who received mental health care in the past year. And Georgia was 47th in the percentage of children with special health care needs whose families received all necessary family support services.

Thousands lack coverage

Georgia was rated second among states in the percentage of children with health insurance whose coverage is adequate for their needs. But that’s a somewhat deceptive statistic, because the state was 42nd in the percentage of children who actually have health insurance.

“It’s not surprising that Georgia ranks so low on child health,’’ said Joann Yoon, associate policy director for child health at Voices for Georgia’s Children, an advocacy group. Yoon said an estimated 300,000 children lack insurance in the state, but that 193,000 of them qualify for government programs Medicaid or PeachCare but are not enrolled.

“Clearly, there’s a shared responsibility between government and community members to enroll and retain children in these programs,’’ Yoon said.

Government insurance programs helped children’s health overall, said the report from the Commonwealth Fund, a nonprofit health care research group based in New York.

“The study demonstrates how policies designed to maintain children’s health insurance and access to health care have helped children get the health care they need, especially in tough economic times,’’ said  Cathy Schoen, Commonwealth Fund senior vice president.

Factors that have lowered Georgia’s child health rankings, including obesity, have become major concerns among health officials in the state.

Much of the obesity problem is linked to economics, among other factors, said Dr. Harry Heiman of Morehouse School of Medicine. “Those people with lower incomes, and lower access to healthy foods and green space, will have higher rates of obesity.’’

Those same financial gaps are evident in other health statistics of Georgia and the South, said Heiman, who is director of health policy for the Satcher Health Leadership Institute at the Atlanta-based medical school.

“When you have a more diverse population, and a poorer population, the needs are going to be greater at a time when budgets are being cut back,’’ Heiman said. “States in the South … will need more resources to care for that population because their needs are greater.’’

What’s being done now

Several new programs, meanwhile, are being implemented to improve Georgia children’s health.

The state has adopted an annual in-school assessment, measuring each student’s cardiovascular fitness, muscle strength, muscular endurance, flexibility and body composition. “There’s [currently] a lot of emphasis on CRTC scores, which may detract from the importance of physical activity during the school day,’’ Yoon said.

School districts in the state are offering students greater access to healthier menu items. For example, the Atlanta Falcons Youth Foundation is partnering with Sodexo-Jackmont and Georgia Organics to promote healthy lunch and breakfast menu items in the Atlanta Public Schools.

To reduce the number of low-birthweight babies, the state Department of Community Health has started a program that offers medical and family planning services for low-income women. The birthweight program has real promise, Emory’s Adams said.

And Georgia is making progress on teenage pregnancy. The state had one of the biggest drops nationally in its teen birthrates in 2009, the AJC reports.

Here’s the link to the Commonwealth Fund study. Click on the map, then click on Georgia to get all of the state’s statistics.

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