Disparities in Maternal and Neonatal Outcomes by Race/Ethnicity

October 30, 2020

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October 28, 2020

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00:00I. Good evening my friends.
00:03Welcome, it says it's a special night
00:06for the Yale Pediatric Ethics program.
00:08We are hosting along with the yellow
00:10program for biomedical ethics.
00:12A special session tonight
00:13with Doctor Rammers Kaiser.
00:14My name is mark material and I am the
00:17director of the Pediatric Ethics Program,
00:19an I welcome you on behalf of that,
00:22as well as the program for biomedical ethics.
00:24Are associates, directors,
00:25Jack Hughes and Serra Hall,
00:27and our manager, Karen Cove,
00:29who was sitting very still in the corner
00:31of frame of your of your zoom picture.
00:34I. Of these these sessions,
00:37the way they go to remind you
00:39those of you who are new,
00:40we will hear from our guest speaker
00:42for about 45 minutes, plus or minus.
00:45After her talk is over,
00:46I'd invite you to submit questions
00:48and will have what amounts to a
00:50conversation in the zoom aerials.
00:51Submit your questions in the chat.
00:53I will take a look at those and
00:55share those with amorous an also
00:57I'll be monitoring this session.
00:59I'll ask cameras and then she will respond.
01:01Then we will have a bit of a conversation.
01:04That way there will be a hard stop.
01:06At 6:30 I'm so I apologize if I
01:08don't get all your questions in,
01:10but I will stick to that agreement
01:12that we will end on time and that I
01:15may go very quickly 'cause I think
01:17it's going to be a very nice session.
01:19I want to introduce you an old
01:21friend of mine who is Doctor Amris.
01:23Kaiser Doctor Kaiser is an assistant
01:25professor of Pediatrics in the
01:26division of Neonatology at Johns
01:28Hopkins University School of Medicine.
01:29She's also the medical director of the
01:31Neonatal Intensive Care Unit at the
01:33Bayview Medical Center at Johns Hopkins.
01:35She received her undergraduate
01:36degree in the History of Medicine.
01:38At the University of Chicago and her.
01:42Anne and her medical degree from Mount Sinai.
01:45She did pediatric residency
01:46at Vanderbilt and of course,
01:48did a fellowship in neonatal
01:50perinatal medicine here at Yale.
01:52So this is her triumphant
01:53return to Yale well yell.
01:55She did some wonderful work over
01:57to school of Public Health.
01:59And in her research interests,
02:01which are her interests are in the perinatal
02:04Epidemiology and health disparities,
02:06where she works to elucidate the
02:08complex interactions between genetics,
02:09environmental context,
02:10maternal age and racial ethnic background
02:12that drive both outcomes and disparities?
02:15And so I've invited to amorous to
02:17come here tonight and she kindly
02:19accepted to speak to what about
02:21those disparities in outcomes for
02:23maternal and neonatal patients?
02:25And with that I want to turn
02:28the floor over to my friend.
02:30From Johns Hopkins,
02:31and most importantly,
02:32this is the best part about the
02:34teaching that we do here and everywhere
02:36is we get to see the students in
02:38the trainees that we work with
02:40go off and do wonderful things.
02:41So we're very proud of Amerson.
02:43Very glad that she made time
02:45to speak with this
02:46for a bit. Deceiving Doctor Kaiser,
02:48please take it away. Alright,
02:50well Doctor Mario, thank you so
02:51much for such a warm welcome.
02:53Give me just a moment to share my screen.
02:57Alright. So thank you so much for
03:05sending the opportunity for me to be
03:08here this evening and to talk with
03:10folks a little bit about a topic
03:13that's near and dear to my heart,
03:15which is disparities in maternal immune.
03:17It'll outcomes by race, ethnicity,
03:19and really trying to dig into that.
03:22Whoops Hold on,
03:26I'm having some technical difficulties.
03:31There we go OK so just ship to frame.
03:38To frame our conversation this evening,
03:40I really thought about this more as an
03:44opportunity to provide some context and
03:46background about kind of the general
03:49epidemiological trends in maternal
03:51and neonatal adverse birth outcomes,
03:54and with that context to try to engender
03:58a conversation as we move into thinking
04:01about issues of disparities in these
04:04trends an in rates of things like
04:08maternal morbidity, maternal mortality.
04:09Preterm birth low birth weight
04:11and infant mortality.
04:13And so as a as I,
04:15I invite the conversation,
04:16but kind of is an overview and
04:19preface to this conversation I
04:21open with this statement that,
04:23compared to their white peers,
04:24minority women, especially black women,
04:26by also including Hispanic,
04:28American Indian, an Alaskan native women,
04:30are two to three times more likely
04:32to experience adverse maternal
04:34and neonatal pregnancy outcomes.
04:36That is,
04:37there's a huge body of research that
04:39has evolved and grown that demonstrates
04:42this time and time and time again,
04:44and it's a very interesting phenomenon,
04:47and we grapple with why that is.
04:50So he in this talk I would like to
04:52explore the literature that describes
04:55epidemiological population level
04:56trends and disparities in maternal
04:59morbidity and maternal mortality.
05:00Preterm birth, low birth,
05:02weight and infant mortality.
05:04And then after we kind of lay the
05:07groundwork with that for context,
05:09I want to talk a little bit more
05:11about the hypothesis that has been
05:13developed to begin to understand
05:15why disparities by race ethnicity
05:18in these different outcomes exist.
05:20And persist.
05:23OK,
05:23so we're going to start out with
05:27some contemporary statistics.
05:28We're going to start in the maternal
05:32realm and then move into the infant room.
05:36Kind of follow it.
05:38Follow that process.
05:40So in terms of maternal mortality,
05:43so it is a devastating occurrence.
05:46It is a devastating outcome,
05:48an extremely upsetting and problematic
05:50for all those who were involved.
05:53However,
05:54it's important to think about it
05:57and contextualize it in terms of
06:00its actual incidence and frequency,
06:02and thankfully it's a relatively rare event.
06:06In 2018,
06:06the most recent year in which
06:09National Statistics were available,
06:10it was documented that there
06:12were 658 maternal deaths,
06:14which is concerning is upsetting.
06:16But that's also in the context of almost
06:193.8 million births in that same year.
06:22So again, the incidents is very,
06:24very low.
06:25It's high acuity,
06:26and there's a lot of implications for
06:29for the occurrence of a maternal death.
06:32So then,
06:33if the incidents is relatively low,
06:35why are we so compelled to really
06:37dig into it and figure out what's
06:40going on and what's driving it?
06:42Well, I think that there are a number
06:45of factors that that drive that,
06:47and one of the biggest factors is
06:49that rates of maternal mortality
06:51in the United States are higher
06:53than in other developed countries.
06:55Specifically, our return mortality
06:56rate is 17.4 maternal deaths per
06:58100,000 live births, and again,
07:00that's the most recent statistics that were.
07:03Released in 2018.
07:04But when you compare that rate to our peers,
07:08were doing a lot worse,
07:10so we're anywhere from you know,
07:121 1/2 to five to six times.
07:15It's happening more frequently in
07:17the United States than it is in use.
07:20Other developed countries that
07:22we consider to be our peers.
07:24And so thinking about that in looking
07:27at that, we know we can do better.
07:30We rank 47 out of 184 countries.
07:33At The Who derived internal
07:36mortality statistics back in 2015,
07:38and we have so much space to
07:41improve and we know we can do it.
07:45The second consideration is that
07:47the rates and maternal mortality
07:50in the United States appear to be
07:53increasing while concomitantly the
07:55rates in some of our peer countries
07:58have fallen and continue to fall.
08:02Here is a graph that just demonstrates
08:05overtime the maternal mortality ratios,
08:07and you can see that they certainly
08:10do begin to rise in the early 2000s
08:14and continue to do so even today.
08:17I say that they appear to rise
08:19because there is some question as
08:21to whether or not this increase in
08:24maternal mortality is driven more
08:27by data collection considerations.
08:29Back in 2003, there was consensus statement.
08:32Look forward to change the death
08:34certificate in the way that it
08:37collected information about maternal
08:39mortality to standardize the process
08:41and make the data more accurate.
08:43Unfortunately,
08:44because that was rolled out and
08:47implemented across all 50 states
08:49over a span of almost 15 years,
08:51there was a lot of variability in
08:54how the data was collected and the
08:57veracity of the data was questionable.
08:59So much so that the National
09:02Center for Health Statistics.
09:03I just stop calculating their maternal
09:07mortality statistics for a period of almost
09:1010 years because of the issues with the data.
09:14So again,
09:14we see this statistic.
09:16We want to address it,
09:17but there is a little bit of uncertainty
09:20as to whether or not maternal mortality
09:23ratios are actually increasing.
09:25But I would argue that most
09:27concerningly about our maternal
09:29mortality rate is that when maternal
09:32deaths are reviewed by external
09:34maternity mortality review committees,
09:37nearly 2/3 of those committees
09:40deemed the deaths preventable,
09:42and so if that's the case,
09:45we have no excuse to not address this
09:48head on and to really find our way
09:53in helping to improve the lives of.
09:56Mothers and infants and all
09:59those around them.
10:01I also just want to make note
10:03as you may have suspected,
10:05that in terms of maternal
10:07mortality rates and statistics,
10:08there are definitely wide racial ethnic gaps.
10:11Unfortunately, minority women and black
10:13women are non Hispanic black women as I
10:17refer to them from this point forward,
10:19having incredible burden placed upon
10:21them wherein they are up to three times
10:24as likely to die from privacy related
10:27cause as white women are and I've put
10:29some of the statistics down there.
10:32For you, this is very worrisome
10:34that there is such a huge divide,
10:37and even though this is an event
10:39that doesn't occur frequently,
10:41the burden is really shouldered
10:43by certain groups,
10:44and we owe it to them to figure
10:46out what's driving the disparities
10:48and to create interventions that
10:51are specifically tailored for them
10:53so that we can begin to close that
10:56gap and assure good health for all.
10:58I think it's interesting to note
11:01also kind of in Devane.
11:03Differences by race in maternal
11:05mortality that the top causes of death
11:09are not consistent across all women.
11:12Mini stratified by race.
11:13We find that non Hispanic black
11:16women that the top causes of death
11:18amongst that group is cardiomyopathy
11:21and cardiovascular conditions.
11:23However, among non Hispanic white women,
11:25mental health conditions account
11:27for the number one cause of death.
11:31And I will take this moment to mention
11:34that this is such an important
11:36topic to study and to research,
11:38but it can be very challenging because
11:41the incidents is so low and because
11:43of that the sample sizes are small,
11:46it can be very difficult to understand.
11:48Further,
11:49stratify your analysis to understand
11:50what's going on within individual groups.
11:53We see a perfect example of that.
11:55Yeah,
11:56right here in that Hispanic women
11:58there is insufficient data.
11:59The numbers are too small for us to.
12:02Figure out with the top cause of
12:05death for that an ethnic group is.
12:07Then I also want to mention that the
12:10leading causes of death we talked
12:12about top causes of death by race,
12:15but top causes of death also vary by
12:18the time at which the death occurs.
12:20So for mothers who passed away within
12:23the 1st two weeks after delivery,
12:25the top causes of death are
12:27postpartum hemorrhage.
12:28Hypertension in sepsis.
12:29However,
12:29for mothers who are able to make it
12:32through that immediate postpartum
12:34period go on to be discharged
12:36from the hospital and go home.
12:38The top cause of death among women.
12:40Seven days to one year after deliveries.
12:43Cardiomyopathy and I just bring that
12:45up to kind of further reinforce the
12:47idea that we need to understand what's
12:50going on with in different populations,
12:52so that we can make sure that
12:55our screening counseling an
12:56interventions are really tailored
12:57and so in this particular case,
13:00to make sure that clinicians
13:01and other medical providers
13:03know what they're looking for,
13:05what their counseling mothers
13:06about to make sure that their
13:09interventions are the most effective.
13:12So you talked a bit about maternal mortality.
13:15Now we're going to move into morbidity.
13:18So the concept of severe
13:20maternal morbidity as an adverse
13:23pregnancy outcome is defined as a
13:25woman who receives a life threatening
13:28diagnosis or she needs to undergo
13:31a lifesaving procedure during
13:33the delivery hospitalization in
13:35order to kind of standardized what
13:38that means a little bit further,
13:40the CDC has curated an maintains a
13:43list now of 21 identifiers of severe
13:46maternal morbidity with associated ICD codes.
13:50So that it's a very easy to figure out
13:52what they are, and that there's a lot
13:55more standardization within the research.
13:56Severe maternal morbidity affects more than
13:5960,000 lumen per year in the United States,
14:03and it's really kind of a warning
14:06sign prior to women have experiencing
14:09a maternal mortality.
14:11So really,
14:12really important to kind of think
14:15about on that continuum of illness.
14:18It is associated with significant
14:21disability on cost.
14:23Just to give you a sense of what kinds
14:25of medical conditions and procedures
14:28are used to indicate a severe morbidity,
14:31I've listed them here for you and I
14:34completely agree when when patients
14:36experience these conditions or have
14:38need for these kinds of interventions,
14:40the acuity and severity of illness
14:43is quite high.
14:46So just to talk a little bit
14:49about the general Epidemiology
14:50of severe maternal morbidity.
14:53Unfortunately for all women,
14:55rates of severe morbidity are increasing and
14:59spend a little bit challenging to kind of.
15:02Cobble together and arrive population
15:04level estimates because there are so many
15:07kind of different fragmented data sources,
15:09but there are a couple of studies
15:12that have come out that use
15:14the national inpatient sample,
15:16which is a large,
15:17impatient database managed by the Agency
15:20for Healthcare Quality and Research,
15:22which its function is to serve as
15:25a representative sample of the
15:27population so they purposefully
15:28sample from different community.
15:30An urban hospitals across the United States.
15:33So that researchers are then able to
15:36calculate and extrapolate from that
15:38smaller sample size to the population
15:41level to derive population level estimates.
15:44So from this study,
15:46it was determined that the overall
15:49rate of severe maternal morbidity
15:51during a delivery hospitalization
15:54increased almost 200% over the
15:56time period from 1993 to 2014.
15:59There is a complementary study that
16:02was conducted by Callahan ET al that
16:06found similar increases over a 10
16:08year period of 75% in the incidents
16:12of severe maternal morbidity's most
16:14frequent morbidity was a blood transfusion.
16:17And it's really remarkable how
16:19much they increased it increased
16:22by almost 400% of that.
16:24Really drove a lot of the
16:26statistics that you're seeing,
16:28but it's also noteworthy to mention that
16:31there were multiple other severe morbidities
16:34that increased by at least 75% over this.
16:37Same over that 10 year time period
16:40that included acute renal failure,
16:43shock from botic,
16:44pulmonary embolisms,
16:45AR DSQMI aneurysms in cardiac
16:48and pericardial surgeries.
16:49And then as severe morbidities as
16:52kind of harbingers or risk factors
16:54for eventual mortality for delivery
16:57hospitalizations where there was
16:59a severe complication that in the
17:02hospital proportionate mortality ranged
17:04from not so much to upwards of 33%
17:08depending on the specific morbidity
17:11that the mother was diagnosed with.
17:14So if we've gotten a little bit of the
17:16lay of the land about how severe morbid
17:20morbidities are increasing overtime,
17:22many different factors could
17:24be contributing to that.
17:25But it's very concerning,
17:27and certainly worthy of our attention.
17:29And now we're going to turn our
17:31attention a little bit to disparities
17:33in the incidence of severe maternal
17:35morbidity's during the delivery
17:38hospitalization specifically.
17:39So there's a very elegant study that
17:41was done in 2018 by M on colleagues.
17:45That use the same national
17:47inpatient sample but a smaller.
17:49Time period from 2012 2015 to specifically
17:52generate population based estimates of #1.
17:55The prevalence of chronic physical and
17:58behavioral health conditions among women
18:00who come in to deliver an and then
18:03to the incidence of severe maternal
18:05morbidity among those women as well.
18:08This is really to understand how
18:10the extent of the problem of the
18:13issue and then Furthermore they
18:16stratified their estimates by race,
18:18ethnicity and group folks into.
18:20Five or six different categories
18:22for the purposes of this talk,
18:23I will focus mostly on non Hispanic,
18:25white and non Hispanic black women.
18:28So they hypothesize that the prevalence
18:31of comorbid chronic conditions would
18:33be higher among minority women,
18:35and they found that to be true,
18:38and it was especially true
18:40for non Hispanic black women.
18:42They also hypothesize that the incidents
18:45of maternal severe morbidity would
18:47be higher among minority women women
18:49compared to non Hispanic white woman,
18:52an more pronounced among
18:54non Hispanic black women.
18:56So they did many fancy analysis
18:58with lots of fancy statistics,
19:01but at the end of the day they they
19:04confirmed both of their hypothesis
19:06and found that minority women,
19:08and specifically not has been in black women,
19:12have a higher burden of disease,
19:14as evidenced through higher prevalence
19:17of chronic conditions and higher
19:19incidence of maternal severe market is.
19:22And what's really interesting is
19:24they went on to do some additional
19:27calculations to figure out basically
19:29that the excess burden if you will.
19:32So if all women experience the
19:34same rates of severe morbidities
19:36and chronic health conditions,
19:39then we would see a 28% reduction
19:42in severe morbidities among
19:44racial and ethnic minority women,
19:46and that reduction would be even more
19:49pronounced for non Hispanic black women.
19:52As we've been talking about South 28% at 41%,
19:56and in addition for all women they
19:59would see about a 15% reduction
20:02in severe maternal morbidity.
20:04So it's it reinforces that there
20:07is a disparity there,
20:09but it's also motivating to see how
20:12much of a difference in how much
20:15of an impact working to mitigate
20:19disparity specifically can have.
20:21Suggested the summary.
20:23Overall trends in maternal morbidity and
20:26mortality are concerning on multiple levels.
20:29One of the biggest challenges is
20:32assuring the quality of data that's
20:35being collected and towards that
20:37end the CDC and other government
20:40institutions have really.
20:42Made a point of developing different
20:45programs to address that need,
20:47because if the quality of the data
20:49is not sufficient then we're not
20:52going to have accurate understanding
20:54of what's going on around us.
20:57I think it also shows us that there
20:59is a need for immediate intervention.
21:03With respect to maternal mortality,
21:05because of the high percentage of
21:07preventable deaths, if these desperate,
21:09deemed, preventable,
21:09then there should be no reason why we
21:12can't figure out how to prevent them.
21:15So that seems like relatively
21:17low hanging fruit.
21:18And then I would argue that further
21:20because of the persistent disparities,
21:23there is a need for the interventions
21:25to decrease mortality and morbidity
21:27to specifically be geared towards
21:29black and other minority women to
21:32make sure that we optimize the
21:34efficacy of the interventions,
21:35and in so doing mitigate disparities,
21:38we want to have good health for all.
21:41And this is 1 Avenue of doing so.
21:45So we've talked again about
21:47mothers and their adverse outcomes,
21:49and now we're going to move into the
21:51infant realm and talk about birth
21:54outcomes and trans in statistics overtime.
21:57So because we're going to be talking
21:59about this for a little while,
22:01wanted to run through a couple
22:03of definitions as in
22:04unitologist pre term birth
22:05is near and dear to my heart.
22:07Makes up a large contingent of the
22:10patient population that I care for.
22:11This refers to infants who are born at
22:13less than 3637 weeks gestation with
22:15the normal gestation lasting 40 weeks.
22:17Low birth weight infants are those
22:19born at less than 2500 grams,
22:21which is about 5 pounds, 8 ounces,
22:23and the infant mortality is the number of
22:26infant deaths per live per 1000 live births.
22:28And those deaths occur prior to
22:31the infant's first birthday.
22:32So prior to 365 days of age.
22:36So you've got all these definitions
22:38and think about birth outcomes.
22:40What's the big deal about pre term birth?
22:43Well, I think that we need to
22:46kind of contextualize it as well.
22:48Pre term birth is the number one cause
22:51of infant mortality as it accounts for
22:54about 1/3 of infant deaths annually
22:56while low birth weight doesn't
22:58have quite the same contribution
23:00to our impact on infant mortality,
23:03it still is a significant risk
23:05factor for infant mortality.
23:07An an importantly survivors of preterm
23:09birth and low birth weight are at risk
23:13for complications in early childhood,
23:15adolescence,
23:15and offload all throughout the life course.
23:18So it's very exciting to think about.
23:22Decreasing rates of pre term
23:24birth to mitigating disparities in
23:26preterm birth and low birth weight.
23:28Because in so doing will directly
23:31drive down your infant mortality rate.
23:34But Furthermore you are working towards
23:36improving the health of individuals not
23:38just during the birth hospitalization,
23:41not just during infancy and childhood,
23:43but across the entire life.
23:45Course is very very important pursuit.
23:48Just a little bit of the Epidemiology of pre
23:52term birth over the last couple of decades,
23:55so we've made strides chipped away at it.
23:58But starting in the 1990s,
23:59they rated pre term birth began to slowly
24:02rise and it did so for about 16 or 17 years.
24:06We saw a 20% rise over
24:08that time point in 2006.
24:10It peaked and then from that point
24:13forward began to decline and is to
24:15over the next eight years or so.
24:18It's worth mentioning that it's a
24:21pretty significant decrease in the
24:24rate of pre term birth that we see
24:26just around 2006 and that was driven
24:29in very large part by a concentrated
24:32effort within the acceptable community
24:34to change their practices regarding
24:36elective Caesarean sections prior to term.
24:39Previously,
24:39the kind of prevailing thought and
24:42feeling had been all the baby at 35 or
24:4536 weeks is close enough to determine
24:47if we need to schedule a C-section.
24:50An non medically indicated see
24:51section A little bit early.
24:53It will be fine.
24:54The baby will be fine but not
24:56completely recognizing that although
24:58the chances of survival were excellent
25:01at that gestation elhage that pre
25:03maturity brings with it its own
25:05set of morbidities and that was
25:07not something to be taken lightly.
25:09That intervention and practice
25:11change was very successful.
25:12You can see that reflected on
25:14a national level by
25:15decreases in the rate of preterm birth.
25:18We have had success for a time for time,
25:22but since 2014 you can see at the rate
25:25is slowly starting to rise and has
25:28done so over these past six years and
25:31we're now back to pre 2010 levels.
25:34So at its peak around 2006 2007
25:37pre term birth rate was around 12%.
25:40We driven it down to around 9,
25:42maybe slightly below that and
25:44now we're kind of coming back up.
25:472 into the time range.
25:51And then we start to think about
25:54disparities in rates of pre term
25:56birth so that there certainly are
25:59African American women have 1 1/2
26:01to two times the risk of preterm
26:04birth as do non Hispanic white women.
26:07Even when you adjust for multiple
26:09socio environmental.
26:10Another confounding factors.
26:11So part so big part over 2 is
26:15you're trying to understand what
26:17drives these disparities and how.
26:20How do how does the magnitude of
26:22those disparities change overtime?
26:24So this graph demonstrates over the
26:27same time period as we look at the
26:30trends and overall rates of preterm birth.
26:33Looking at the difference between
26:35rates in non Hispanic black and
26:38non Hispanic white infants.
26:39So similar,
26:40so thankfully the risk difference
26:42has been slowly declining.
26:44Since about 2006 and it looks like
26:47there's actually been a very nice steady
26:50downward trajectory of that risk difference,
26:53so that gap was bit by bit
26:56coming closer was narrowing.
26:58But unfortunately it started
27:00to rise in about 2013.
27:02This is kind of concomitant with the
27:05overall trend in uptick of pre term births.
27:09An there is difference has now surpassed 5%,
27:13which is above where it was kind of
27:16during the height of its decline.
27:19If you will.
27:20So that is something concerning an
27:23warrants further investigation.
27:25Overtime to make sure that that
27:28trend doesn't continue.
27:29OK,
27:29so you've talked about pre term
27:32birth and we're going to transition
27:35to low birth weight.
27:37So the trends that kind of overall
27:41epidemiological trends in low birth
27:44weight has been somewhat similar
27:47to pre term birth in that they
27:50rose for a period of 15 years,
27:53give or take an again by that 20%
27:56mark they peaked around 2006.
27:59Plateaued and then began to
28:02decrease an natured in 2012.
28:06But I think the biggest thing
28:08to note is that the.
28:10The the magnitude of that change is much
28:14smaller than what we saw in pre term birth.
28:18However, similarly to pre term birth,
28:21we are now seeing that rate
28:24of low birth weight rising.
28:27It's risen 4% in the last seven
28:30years and is currently at 8.28%,
28:33which is higher than it was.
28:36At its peak in 2006,
28:39before falling.
28:40So again,
28:41something that we need to continue
28:44to follow and see how this evolves
28:46and see what that tells us about.
28:49The nature of drivers of disparities.
28:52I will also mention on that you
28:54can you can see that the risk
28:57difference between non Hispanic white
28:59and non Hispanic black low birth
29:02weight rates is fairly constant.
29:04Starks to kind of narrow a little bit,
29:08but we're starting to see widening that risk
29:12difference in these in the last few years.
29:16This is kind of a recapitulation of that.
29:20OK, so we talk through kind of
29:22trends in preterm birth and low birth
29:25weight Epidemiology that they're
29:26not exactly the same similar to one
29:29another in their overall trends.
29:31Overtime, the infant mortality has
29:32followed quite a different trend.
29:34First and foremost is worthwhile to
29:37note that the amount of data and
29:39the timeline over which that data
29:41was collected is a lot more robust
29:44and extensive than what we have,
29:46especially your pre term birth,
29:47because the statistics have been
29:49captured for so long.
29:51So we have good statistics starting at
29:53the turn of the 20th century actually
29:56show the rates for non Hispanic,
29:58non Hispanic black infants,
30:00and so that we can get a great sense of
30:03what the trends have done overtime and
30:06what the risk difference has been overtime.
30:09So the overall happy story.
30:11Over the entire course of the 20th century,
30:14we see a continual decline
30:16in infant mortality rate for
30:18both black and white infants.
30:20However,
30:20what is striking is that the risk
30:24difference really didn't budg with the
30:27entire first half of the 20th century,
30:31and it may have widened at
30:34subsequent to that point,
30:36so there is 2 fold greater infant
30:39mortality rate for black newborns
30:42compared to white newborns,
30:44and it has really maintained that
30:47magnitude of difference if not widened.
30:50Despite advances in the treatment
30:52and prevention of disease and
30:54advances in sanitation, housing,
30:56public health interventions,
30:58and that trend continues even to the most
31:02recent statistics published in like 2017.
31:05So in summary,
31:06thinking about trends in birth outcomes,
31:09unadjusted trends in pre term birth,
31:11low birth weight,
31:12an infant mortality rate are similar,
31:15but they're not interchangeable.
31:17As we discussed.
31:18I think really,
31:19what what always strikes me is
31:21how little variability there is
31:24in low birth weight overtime.
31:26How much more variability,
31:28comparatively infrequent birth,
31:29there has been overtime,
31:31and while both preterm birth and
31:33low birth weight look like they're
31:36starting to tick up a little bit.
31:39Infant mortality rate continues to decrease.
31:41As we noted that despite overall
31:44decreases in the crude rates
31:46of all three of these.
31:51Disparities persist across all three
31:53birth outcomes and the magnitude of
31:56the difference between rates by race.
31:59Ethnicity hasn't changed
32:00meaningfully over that time,
32:02at all, so we've done well with
32:05improving health kind of globally.
32:08But we've not done well in
32:11addressing this persistent disparity.
32:13And as I mentioned earlier,
32:15it's interesting to note that
32:17the disparity persists even after
32:19adjustment for traditional risk factors,
32:21and So what that brings to
32:24mind for me is to say, OK,
32:27so if we adjust for all of these
32:30different risk factors and it
32:32doesn't make a difference that
32:34there's still this excess risk.
32:37There is unmeasured risk we haven't
32:39been able to account for it,
32:40so our job really is to try and
32:43figure out what is that unmeasured
32:45risk and how do we account for it.
32:47But because it's kind of a. So complex.
32:51The greater question to ask is
32:54how do we conceptualize the risk?
32:57Do we think about risk as individual,
33:01individually identifiable risk factors?
33:02Do we think about combinations of
33:05risk factors? Groupings of exposures?
33:07Are we thinking about social context?
33:10Are we thinking about?
33:13Biologic influences?
33:14Or are we thinking?
33:16Are we taking a step back and
33:19thinking about frameworks
33:22for conceptualizing the risk?
33:25And so that's what we're going to
33:28talk about a little bit more right now,
33:31so we're now going to move in now that
33:34we've kind of explored a little bit
33:36the existence of an persistence of
33:39disparities in poor birth outcomes.
33:42Overtime we're going to talk through
33:44the different hypothesis that have
33:46been put forth to try to explain and
33:49contextualize these disparities in
33:50adverse pregnancy and birth outcomes.
33:53With the focus is really on my birthday.
33:56Pumps
33:59So there are many, many of them
34:01come from the social Sciences,
34:04and many of them have been
34:07around for many many years,
34:09and so that's where I'm going to start
34:13with weathering hypothesis that was
34:15originally developed in the late 70s,
34:18early 80s by Doctor Arlene Geronimus,
34:21who is at the University of Michigan.
34:24Ann. She was trying to think
34:27about an explanation for.
34:294 two kind of simultaneous observations.
34:32One was the excess infant mortality
34:35rate among black infants and the
34:38other was why the teenage pregnancy
34:41rate among non Hispanic black
34:44teenagers was markedly higher than
34:47among non Hispanic white teenagers.
34:50The prevailing thought at the time was
34:54that teenagers have an increased risk
34:57of poor birth outcomes that included
35:01pre term birth and low birth weight,
35:04which then kind of are perpetuated
35:07into infant mortality that within
35:10the African American community there
35:13was a higher incidence or higher
35:17percentage of women of childbearing
35:19age who were teenagers having babies.
35:22That it was these teenagers who accrued
35:26the excess risk an who were really
35:29driving the excess infant mortality
35:32rate because of because of the risk
35:35associated with with teenage birth. She.
35:41Did not buy that an actually thought.
35:45Quite the opposite.
35:47She was struck by the.
35:50Perpetual.
35:51Social disadvantage that many
35:53women within African American
35:55community we're experiencing,
35:57and she thought that it was actually
36:00the older women and the oldest women
36:03and not the younger or youngest
36:05women who were accruing the increased
36:08risk of poor birth outcomes,
36:10which was then translating
36:12into excess infant mortality,
36:13and that was older women that
36:16were driving that disparity.
36:18So her original hypothesis was at
36:21the health status of black women
36:24begins to deteriorate earlier.
36:26Specifically, in young adulthood,
36:28as a consequence of prolonged exposure
36:31to social and environmental disadvantage.
36:34Because or or in concert with this
36:37earlier deterioration of health status.
36:40Reproductive health also suffers
36:42and begins to deteriorate earlier
36:44as well as more rapidly among black
36:47women compared to white women.
36:50And this in turn results importer
36:52birth outcomes at relatively earlier
36:55ages for black but not white women,
36:58and that this then propagates a
37:00widening of disparities in poor birth
37:03outcomes with advancing maternal.
37:05Age.
37:06Now keep in mind that the original
37:09application in the original outcome
37:11in this study was infant mortality
37:14and the original population to
37:16which it was being applied.
37:18Was African American women and and
37:21this was the hypothesis to explain
37:24disparities in infant mortality rates.
37:26It's a fascinating hypothesis.
37:29There's a lot of investigators who
37:32have taken it an investigated it
37:35and applied it to different datasets
37:38an it's really come into its own
37:41and to be accepted.
37:44Mainstream hypothesis,
37:45but in in that process of
37:49evaluation it has been expanded.
37:53From From an explanation for
37:57disparities in infant mortality,
38:00to be applied as an explanation
38:03for differences in any health
38:06outcome by race ethnicity.
38:08So instead of justice African
38:11American women experiencing this now
38:14it's any African American person.
38:16With any health outcome
38:19where there is a disparity,
38:21Anet has Furthermore been more
38:24broadly generalized to apply to any
38:27marginalized or minority population to
38:30explain disparities in health outcomes
38:33compared to the majority population.
38:36So it's interesting to see that evolution,
38:40but I think it it does beg the question.
38:45Is this hypothesis inappropriate?
38:49Explanation for.
38:51The existence of health disparities
38:53in in all of these different
38:55contexts and applied to all of
38:57these different populations.
38:58Or do we need to be very thoughtful about?
39:02Evaluating two what populations?
39:06This can be applied.
39:10So her moving kind of from from
39:12the social Sciences a little bit
39:15into the Biological Sciences and we
39:17start to talk about allostatic load.
39:20I like to talk about this next because
39:22it's kind of the biological objective
39:25measurement counterpart to weathering.
39:27So the concept of allostatic load
39:29is that this is this concept is
39:32representative of the cumulative
39:34wear and tear on the body's systems.
39:37That is 02 repeated adaptation to stressors.
39:40I do want to emphasize that this
39:43is wear and tear that is due to
39:46not to the stressor itself,
39:48but to the body's reaction to your
39:50adaptation to this Dressler stressor.
39:53We think about Al static load
39:55as the physiological burden
39:57that's imposed by stress,
39:58and it can be kind of quantified
40:01and indicated by thinking bout
40:03two categories of biomarkers.
40:05Do you get your primary mediators or
40:07biomarkers in your secondary mediators?
40:10The primary media?
40:11Are biomarkers are physical substances
40:14at the body releases in response to
40:17stress and the secondary mediators
40:20are the effects that the body.
40:22Feels from the release of
40:24those primary mediators,
40:26so the example of being a primary
40:28mediator might be epinephrine
40:30that your body is releasing in
40:32response to a stressful situation,
40:35and the secondary mediator would
40:37be an elevated blood pressure in
40:40response to epinephrine release.
40:42Outside it,
40:43load is operationalized as a numerical score.
40:46Some scale of zero to 10,
40:49a score of three to four correlates with an
40:52increased risk of morbidity and mortality.
40:55An, as I mentioned previously,
40:57this this approach is really
40:59able to quantify.
41:00I would argue the concept of weathering.
41:03There's no built into weathering.
41:05There was no objective measurement.
41:07There's no way to measure.
41:10Its effect,
41:11its extent,
41:12but being able to develop the outside
41:16load score as kind of the numerical
41:20representation of weathering.
41:22OK.
41:22So will then move into thinking about
41:26the life course perspective as a
41:30framework for understanding disparities,
41:33and this one has really come into its
41:36own in the last couple of decades is
41:39really kind of an integrative approach,
41:42so the the idea of a life course
41:45perspective is that early life
41:48experiences have the ability to
41:50shape health not only in the moment
41:53but across the entire lifetime.
41:56And potentially across generations
41:58within the life course perspective,
42:00there is an emphasis.
42:02The timing and duration of
42:04experiences and exposures and the
42:07importance of when things happen and
42:10that is because kind of thinking.
42:13A development in a developmental
42:15context that there are critical
42:18periods of development in the lives
42:20of all of us and they coincide with
42:24times when there's a lot of growth,
42:27development, and activities so that
42:29things like during fetal life during
42:32the first months, two years of.
42:34Infancy and childhood,
42:35when the rate of growth and formation
42:38of GNU connections and all these
42:40different things are going on
42:42and then we have another period
42:44during adolescence and puberty.
42:46When that happens again.
42:48So the the purpose of having
42:50particular attention to the timing
42:53and duration of these early life
42:55experiences is that the magnitude
42:58of the effect of the experience,
43:00positive or negative,
43:01can change based on whether it
43:04happens during a critical period
43:06of development or outside of that
43:09period of development and the effect
43:11of these different experiences is to
43:14change the health trajectory overtime.
43:16So thinking about the health trajectory's.
43:18As I've malleable and responsive
43:21entity that will change in reaction to
43:25different stressors and exposures an
43:28it's this conception that really helps
43:31us to think about adult health outcomes.
43:35ANAN Health later in life as being
43:39intimately connected with the early life
43:42experiences and the importance of thinking
43:45back when you are trying to understand.
43:49Why there might be?
43:52Differences or disparities in
43:54outcomes that present in older age
43:58that that you were risk factors.
44:01Protective factor could be very remote from
44:06the the manifestation of health or illness.
44:10In addition,
44:11of course,
44:11protective also explicitly considers
44:13the role of social context,
44:15not just at one point in time but
44:17overtime and how the how that ongoing
44:20context and changes in context can
44:22shape and shift health trajectories.
44:25And this is again particularly
44:28relevant when we're thinking
44:31about the childhood or early.
44:34Early shaping of health and disease
44:36trajectories over the life course
44:39and the incidence of chronic disease.
44:44So we kind of talked about these
44:47different frameworks that really come
44:49out of the social Sciences tradition.
44:51We haven't talked as much about
44:54the hard Sciences and so one of the
44:58additional considerations that I
44:59wanted to be sure to bring into this
45:03conversation when we start to think
45:05about how do we frame explorations
45:08for understanding disparities in
45:10health outcomes is genetic factors.
45:12Now I know that there are.
45:15Strong opinions on both sides
45:17about where genetic factors lie,
45:20but I think that there is a very
45:23strong argument to consider genetic
45:26contribution when evaluating
45:28disparities in health outcomes.
45:30An for me, birth outcomes specific
45:33to disparities in reset.
45:35Pre term birth,
45:37we know that there is variation in
45:40certain characteristics like broccoli and
45:43just stational age between populations.
45:46And at this May in fact
45:48influence birth timing.
45:50In addition,
45:51we know that there's a a genetic
45:53component or a strong genetic component
45:56to birth timing in that a prior history,
45:59either personal or familial,
46:01of pre term birth increases risk.
46:03So if a mother has had a
46:06previous pre term birth,
46:08she's at increased risk for having
46:10a subsequent preterm birth,
46:12and similarly if she herself
46:14was born pre term,
46:16she has an increased risk
46:18of having a pre term birth.
46:20Or if she has a family member such
46:24as the sister who was born pre term,
46:28she also has an increased risk
46:30of delivering a preterm baby.
46:33In addition,
46:34heritability studies of pre term
46:36birth have demonstrated that.
46:3820 to 40% of the variability in
46:40preterm birth can be attributed to genetics,
46:43so it seems like.
46:46For looking looking at associations between.
46:51Genetics and pre term birth.
46:53Broadly that there is a strong case to
46:56be made that genetics play a factor.
46:59So if we think that you guys can play
47:02a factor in birth timing and pre term birth,
47:06could it also play a role in
47:08drive in driving disparities in
47:10pre term birth and birth timing?
47:12It's interesting to note that in
47:15Genome wide Association studies when
47:17they've been stratified by race,
47:18ethnicity and and there is an analysis of.
47:21Which single nucleotide polymorphism's
47:23or which genetic variants are
47:26associated with pre term birth?
47:27Those may or may not be the same
47:30for different populations that
47:32are defined by race ethnicity.
47:34It's been challenging though,
47:36because the results have been very
47:39difficult to reproduce and we are.
47:41We are understanding more and more
47:44that individual variance produce
47:46a very small magnitude of affect,
47:48so you may need to have a lot of.
47:51A lot of variance to have to have the
47:55manifestation of a very small effect.
47:58And then there's also the additional
48:01challenge of the skepticism of
48:04sufficient homogeneity among self
48:06reported African Americans in in
48:09conducting these genetic studies
48:11and how much.
48:13Heterogeneity is there due to
48:16mixing between folks of African
48:20ancestry and European ancestry.
48:23So all that being said,
48:25I think it makes the case to say yes,
48:28we should consider genetic factors,
48:29but it's not a guarantee.
48:32So. With all of that in mind,
48:37where do we find ourselves right
48:39now in terms of understanding
48:41and evaluating disparities in
48:43health outcomes in birth outcomes?
48:46And how can we leverage what we talked
48:49about today to make forward progress?
48:52So I think. At this point in time,
48:57based on the events of these past months
49:01and years and all of the work that
49:05has gone into helping us to understand
49:09what could be driving disparities,
49:12it's undeniable that structural racism
49:15an other social determinants of health
49:18are significant drivers of disparities.
49:21We know that the legacy of slavery
49:24is still active in our day to day
49:27lives and still influencing and
49:29informing health all and it has been
49:33pervasive in the insidious and very
49:35challenging to identify an address.
49:38But it must be addressed in
49:41order to improve health.
49:43So we understand that.
49:47External factors,
49:49an environment and greater societal
49:52structure plays a role.
49:55However, it's not clear that that's the
49:59only driver an is there still space for
50:04other contributors to be investigated more?
50:08Thoroughly and rigorously.
50:11So I just wanted to talk a
50:15little bit about the concept of.
50:18Genetics, genomics and personal biology.
50:20When it comes to conversations about
50:23race and disparities in outcomes by race,
50:27so time and time again,
50:29we hear that race is a social construct.
50:33And so because of that,
50:35there's no biological underpinning or
50:37no genetic underpinning to that idea,
50:40and there's kind of an 1 one side people
50:44who feel that race is a social construct.
50:48That's all it is.
50:50An can't be can't ever be anything more.
50:53And then there are kind of a contingent
50:57of folks who see race as a potential
51:01genetic or biological construct.
51:03Slightly different perspective.
51:05So if we dig into this idea that
51:09race is a social construct,
51:11what it means is that conceptually it
51:14is fluid and it can change based on
51:17socially derived definitions is not fixed.
51:20It's not innate,
51:21and because of that there is
51:24no genetic basis to it.
51:27And Furthermore,
51:27some would argue that there is
51:30no relationship between race and
51:32innate biological characteristics,
51:34instead arguing that we are all one race.
51:38We are all human.
51:40And so there are 4, four that viewpoint.
51:45There are a few reasons that commonly
51:48genetics is rejected as an explanation
51:51for disparities in health outcomes.
51:54One common one is the observation
51:57of the statement that there is
52:00greater genetic variability within
52:02populations than between populations,
52:05and this was really this kind
52:08of came to the fore.
52:11It was popularized by Richard.
52:13We want him back in the 70s who
52:16was looking at variation in blood
52:18group proteins an he found that 85%
52:22of the variation in blood protein
52:24types could be accounted for by
52:27variation within populations.
52:28An races and only 15% by variation
52:31across them. So he had taken.
52:33He had a large contingent of
52:36subjects who he divided into races
52:39and then look into see.
52:41Ann. If there was a.
52:45What the genetic variability was.
52:48And not surprisingly,
52:49based on that methodology came up with
52:52these results and concluded that most
52:55variation between humans because of
52:57differences between individuals and
52:59not differences between populations.
53:01So we have that is 1 Parliament.
53:04Another reason for the rejection
53:06of genetics as an explanation for
53:08disparities in health outcomes, I think,
53:11is a very real and well founded fear
53:15that history will repeat itself.
53:18In the past, medicine and science
53:23has been used and manipulated too.
53:29Create, maintain an propagate hierarchies
53:32of worth and lend credence to them from
53:38a scientific standpoint or endorsed
53:41by scientific principles objective.
53:44Objective principles And that.
53:50And as has happened,
53:52not only was kind of science
53:54and medicine manipulated,
53:56but then once that manipulation happened,
53:59there is complicity on the part
54:02of the scientific and medical
54:05establishment to stand up against that.
54:08Miss Construction of of results
54:11are of the science and a concern
54:14that if we start to go down this
54:17path way of thinking about genetics
54:21as drivers of disparities in.
54:23Outcomes by race that we might
54:26find ourselves back there.
54:28And that also in so doing there is
54:34D humanization that then results.
54:38In or allows for the justification
54:41to perpetuate social inequality,
54:43which is what we are all fighting so hard to.
54:49Get ourselves. Out of and on better footing.
54:54And then the last concern is
54:56that there is a fear that the
54:59characterization of race as a fixed
55:01or innate characteristic that cannot
55:04be changed absolves responsibility on
55:06the part of medical professionals.
55:09Investigators on the other stakeholders
55:11in society to intervene to improve
55:14the disparities.
55:14They thought that if there's
55:17a genetic predisposition,
55:18there's nothing we can do about it.
55:21So why try or the idea that?
55:24Biology is destiny.
55:25Ann and I just bring this up because in
55:29in the conversations and interactions
55:31that I've had in conversations
55:34about disparities and understanding
55:37drivers of disparities and talking
55:39with folks who come more from a
55:43social Sciences training background.
55:45There definitely is push back
55:48against that idea,
55:49and these are some of the concerns
55:54or objections that are cited.
55:57However,
55:57I think there are also reasons to accept
56:00genetics as a potential explanation
56:02for disparities in health outcomes.
56:05I think it's it's very the idea
56:07that people of the same race self
56:10identified race share common genetic
56:12traits or variance is valid and
56:15that has to some extent been born
56:17out in the scientific literature,
56:19and I think we also can't ignore
56:22the fact that when we adjust for
56:24multiple con founders who try
56:26and understand this relationship.
56:29And that adjustments fails to account
56:31for the disparities in outcomes by race.
56:34It opens up the possibility that
56:37there's an underlying predisposition
56:38towards developing the outcome.
56:40That is biologic that is genetic
56:42as not to say that that's the
56:45entire T of the explanation,
56:47but to refuse to entertain
56:50that as a possibility.
56:51I think is shortsighted.
56:54I would Furthermore going to say
56:56that in there been some challenges
56:59in growing pains in the past,
57:02there was alot around the time that the
57:05human genome was sequenced completely
57:07and there was all this excitement
57:10about the endless capabilities of
57:12genome candidate gene studies in
57:15Genome wide Association studies.
57:17In being able to finally help us
57:19understand the kind of biologic and
57:22mechanistic underpinnings of disease.
57:24There was a lot of confidence,
57:27perhaps misplaced over confidence in the
57:30ability of variation at the genome level,
57:33to explain disparities in health outcomes
57:36and overtime as it has become clear that.
57:40The extent to which genetic variants
57:43do not independently cause complex
57:45disease is very great that investigators
57:47have been humbled and more willing
57:50and more accepting and more excited
57:52to try to take a step back and say,
57:56OK, well if it's not this one
57:59genetic variant in and of itself,
58:02how do I evaluate combinations
58:03between different parts of the genome
58:06between different modifications,
58:08protein expression, etc etc?
58:09How do I evaluate interactions with?
58:12The environment.
58:13How do we kind of look for
58:17those higher level?
58:19Interactions an and higher level.
58:24Associations between different
58:25factors that individually may not
58:28give us the answer we're looking for,
58:31but collectively may get us there.
58:34I think that there's no more of
58:36an emphasis on the biology of the
58:39individual as dynamic and influenced
58:42by the surrounding environment,
58:44and there's less emphasis on a fixed
58:47genetic code that there are fixed
58:50parts and there are mobile parks and
58:53we need to investigate both pieces and
58:56that Furthermore genetic factors and
58:58the contribution of genetic factors
59:00to disparities can now be interpreted
59:03more broadly and conceptualize more broadly.
59:06Not just the genetic code itself,
59:09but all of these other again modifiable
59:13factors that downstream impact how.
59:16That impacted the interactions and
59:19reactions with this surrounding environment,
59:21so that includes studies of the genome
59:25epigenome, the metabolome proteome,
59:26transcriptome microbiome, etc etc.
59:29Multi omics.
59:31So just a couple of parting thoughts.
59:36Through the process of preparing
59:38this presentation and thinking
59:40about these disparities,
59:41I was struck again by the thought
59:44that complex diseases really are
59:46multifactorial and variation in
59:48risk is unlikely to be caused by a
59:51single factor acting in isolation.
59:53So whether that's a single exposure,
59:55whether that's a single snook,
59:57it's unlikely that that that one piece
01:00:01will account for the entire T of what
01:00:04we're seeing in terms of the disparities.
01:00:07There are lots of different hypothesis
01:00:10for understanding disparities
01:00:11in pregnancy and birth outcomes,
01:00:14and it's important to remember that
01:00:16they are not mutually exclusive,
01:00:19so there is no need to necessarily
01:00:22discount any of these hypothesis upfront,
01:00:25but rather to think through them,
01:00:28entertain them,
01:00:29evaluate them and really try to
01:00:32figure out does this hypothesis
01:00:35fit in the context of this?
01:00:38Relationship and this outcome
01:00:39that I'm trying to examine.
01:00:42And then I also just wanted to make
01:00:45mention of the fact that in the
01:00:48United States self identified race
01:00:51is reasonable proxy for genetic ancestry,
01:00:54and I think that that is the direction
01:00:57where folks are moving who really are
01:01:00interested in cultivating a multi multi
01:01:03faceted multidisciplinary approach to
01:01:06evaluating disparities in outcomes.
01:01:09While it's true that race
01:01:11is a social construct,
01:01:13differences in genetic ancestry track
01:01:15reasonably well alongside those constructs.
01:01:18So in the absence of having
01:01:21readily available.
01:01:22Gene typing for all it seems a
01:01:25reasonable proxy to use for race
01:01:28as a proxy for genetic ancestry
01:01:30while recognizing its limitations
01:01:32and the absence of absolutes.
01:01:35And it's interesting to note also
01:01:38that self identified African Americans
01:01:41in the United States derive about
01:01:43on average 80% of their genetic
01:01:46ancestry from enslaved Africans.
01:01:48So although there is a lot of
01:01:51conversation about admixture,
01:01:52and certainly that percentage
01:01:54changes and fluctuates.
01:01:56Based mostly on geography and where
01:01:58in the United States you are.
01:02:01Again it lends additional credence
01:02:03to the idea that self identified
01:02:06race can be used as a reasonable
01:02:09proxy for genetic against ancestry.
01:02:12And ultimately,
01:02:13that by staying open to all these
01:02:16different possibilities and new
01:02:18ideas as a researcher,
01:02:20you have the opportunity to
01:02:22leverage all of this knowledge and
01:02:25all of this power to help,
01:02:28to disentangle in understand drivers
01:02:30of disparities in birth outcomes.
01:02:33Thank you very much.
01:02:35Wow, Amherst, that was it.
01:02:37That was
01:02:38an amazing talk. Thank you very much.
01:02:40I'm sure there's going to be.
01:02:42There's already some questions lined
01:02:43up and I'm sure if you want to ask,
01:02:46but I'd like to take my moderators
01:02:48prerogative and ask the first question
01:02:50if I understood you correctly.
01:02:51You spoke about how the usual
01:02:53demographic things that we started
01:02:55to try and explain the disparity
01:02:57didn't pan out as the cause of those.
01:02:59If we control for things like income,
01:03:01education, etc.
01:03:02That that we still see the
01:03:04disparity that was.
01:03:05That was your point, so.
01:03:06What an and in in putting
01:03:08together all the things you said,
01:03:10it leads me to wonder,
01:03:12can we control for other things?
01:03:13We talk about the influence, for example,
01:03:15of stressors of environmental stressors
01:03:17of the history of racism attrition.
01:03:19Is there way to control some
01:03:20measure for that?
01:03:21Which makes me wonder,
01:03:22how does the United States in that
01:03:24disparity that black white disparity?
01:03:26How does the United States
01:03:28compared to other countries?
01:03:29Have you know we saw a lot of of usdata,
01:03:32but I wonder if other countries that
01:03:34perhaps have a different history or
01:03:36a different current environment.
01:03:37Um, if their disparity is higher or lower,
01:03:39or how that looks.
01:03:41That's a fantastic question. I have two,
01:03:44so it's something that I'm interested
01:03:46in really getting into in the future,
01:03:49but I have to admit I haven't
01:03:51looked at those statistics in
01:03:53a really long time, so I don't.
01:03:56I don't know that I have a great
01:03:58answer for you about kind of
01:04:00contemporary outcomes and disparities
01:04:02in places like written, for instance,
01:04:05so I'm not I'm not sure off hand.
01:04:08I do recall from way back that there was.
01:04:11A study that was looking at
01:04:15risk of preterm birth among.
01:04:18Among parents who were not of the same race,
01:04:22so they looked at the risk of pre term
01:04:25birth for a black mother and a black father,
01:04:29a black father and a white mother.
01:04:33A black mother and a white father and
01:04:36a white mother and a white father.
01:04:39And they found that the risk of
01:04:41preterm birth was the highest for the
01:04:44couple where both parents were black.
01:04:46The lowest where both parents were
01:04:48white and for the two interracial
01:04:51couples the risk was in between.
01:04:53The risk was higher when the mom was black.
01:04:57And when the mom was white and I
01:04:59believe that that study was either
01:05:01done primarily or there was a like a.
01:05:04Kind of a validation study that was done.
01:05:08It was not in this country, but I can't.
01:05:11I can't remember if it was Northern Africa.
01:05:14I think it may have been Northern Africa.
01:05:17This is fascinating stuff.
01:05:18Thank you so much.
01:05:20I'm going to get to some
01:05:21of these questions here.
01:05:22I'd invite you folks to put your questions.
01:05:25I see summer in chat in summer,
01:05:27in Q&A, so going forward,
01:05:28go ahead and put your questions in chat,
01:05:31but I'm going to look and see some
01:05:33stuff that's in the Q&A portion.
01:05:35So amorous someone asks,
01:05:36excuse my ignorance,
01:05:37but what are some examples of
01:05:39the environmental disadvantages?
01:05:39I think this question came through
01:05:41relatively early in your talk
01:05:42about the disadvantages that
01:05:44could influence the disparity.
01:05:46Absolutely, so it's it's many of
01:05:49the things that we're talking about
01:05:52a lot these days, so it's poverty,
01:05:55intergenerational poverty,
01:05:56its lack of education,
01:05:58lack of access to medical care,
01:06:01lack of access to healthy foods.
01:06:04All all those kinds of socio
01:06:09environmental challenges.
01:06:10Concerns about personal safety like
01:06:12are you live in a safe environment?
01:06:14Are you able to get to work?
01:06:17Is that in a safe environment?
01:06:19Do you have what kind of transportation
01:06:21do you have access to? Is it?
01:06:24Are you relying on public transportation?
01:06:26An it is stressful to be able to manage that.
01:06:29So it's all these kind of different different
01:06:31levels and different considerations,
01:06:33and it's.
01:06:34Yeah, I'll stop there.
01:06:36Thank
01:06:37you, so here's a.
01:06:38It's more of an observation and suggestion.
01:06:40Thank you for this overview.
01:06:42Doctor Kaiser, I would suggest that
01:06:44instead of genetics at the focus
01:06:46on researching perinatal health,
01:06:48disparities should be on epigenomics
01:06:49on how the adverse exposures
01:06:51influence gene expression and
01:06:52you actually commented on that.
01:06:54Briefly, talk about genomics as well.
01:06:56And also there are genetic methods
01:06:58and platforms to determine ancestry so
01:07:01we can control for that in studies,
01:07:03even among racial ethnic groups in it.
01:07:05Things to my something I thought of when
01:07:08you mentioned you want is work in 1972.
01:07:10I couldn't help wondering.
01:07:11I wonder what level of sophistication he
01:07:13had for looking at the genetic variation
01:07:15both within groups and between groups etc.
01:07:17Absolutely. Absolutely thank you for that.
01:07:21I appreciate that feedback. OK,
01:07:23now here's some more
01:07:24thoughts from your audience.
01:07:26Can you comment on Elizabeth how's work
01:07:28in New York City that showed that both
01:07:31black and white women were at higher
01:07:33risk for morbidity and mortality at
01:07:35primarily black serving hospitals,
01:07:37suggesting that a significant
01:07:39tributed contributed to disparities
01:07:41is poor quality of care.
01:07:43Similarly, could you comment on why
01:07:45outcomes in the US are substantially
01:07:47worse than other high income countries?
01:07:49How are the health systems
01:07:50in those countries different?
01:07:52How do they do it better?
01:07:54ETC so the first part of her
01:07:57question related to white women
01:07:59and the morbidity mortality being
01:08:01cared for it in hospitals that
01:08:03primarily sort of black communities.
01:08:06Absolutely, so I have read her work an
01:08:10she's got kind of a lot of different
01:08:13facets to this specific questions
01:08:16that she asks in answers. It does.
01:08:21Begin to speak to quality of care,
01:08:24but I think that there's also
01:08:26there also issues of residential
01:08:28segregation that may be at play.
01:08:31To be honest, I would have to go back
01:08:34to that specific article and read a
01:08:38little bit more about what her like,
01:08:41how the analysis was structured,
01:08:43but I appreciate the comment and I
01:08:46think that must absolutely there
01:08:48there is embedded in all of this.
01:08:51Quality of care access.
01:08:53If care and variability in
01:08:55outcomes by hospital,
01:08:56that's its own kind of its own contingent.
01:08:59An area of research as well.
01:09:01And it sounds like this study
01:09:03falls into that as well.
01:09:05So yes, that's most likely a part of it,
01:09:08but how it fits into the.
01:09:11The entire T of the context.
01:09:13The broader context is a
01:09:15little bit challenging to say.
01:09:17At this point, thank
01:09:18you. Emirates to these studies and
01:09:20disparity control for the higher
01:09:22incidence of hypertension and obesity
01:09:24in Blacks compared to whites. Yes. Yes,
01:09:29so great that. Here's a
01:09:32question for me.
01:09:33Here's a question for the modern very nice.
01:09:35Will this presentation be available
01:09:37after the live web and R?
01:09:39And the answer is thanks to our friend,
01:09:42Doctor Kaiser? Yes,
01:09:42this will be available on the website
01:09:45for the program for biomedical ethics.
01:09:47If you just go to biomedical ethics at Yale,
01:09:50you will find it there very soon.
01:09:53OK, another question.
01:09:54I think for our speaker,
01:09:56if there is a significant
01:09:57epigenetic component to
01:09:59disproportionate black mortality,
01:10:00how can you disentangle that from
01:10:02structural racism and the history of
01:10:05anti black racism in the United States?
01:10:07So there's a pretty easy question so.
01:10:10But I mean,
01:10:11I'll put an important one affair question.
01:10:13This is this is hard stuff
01:10:15to China on sort of stuff.
01:10:17It's also a little bit frustrating
01:10:19how with all the genetic technology
01:10:21and data available as well as all
01:10:23the demographic data available that
01:10:25we still don't have a better answer
01:10:27for why this disparity or a complete
01:10:29answer for why this disparity exists.
01:10:31But perhaps you'd like to.
01:10:33Poverty caused by structural racism.
01:10:35All that I'm sorry.
01:10:36That's the next question should be so
01:10:38the last question will get to that
01:10:40in a moment. Netex from structure isn't.
01:10:43I mean, I think that's a really
01:10:46excellent question and I think we're
01:10:49at the point where we're only just
01:10:51beginning to delve into and beginning
01:10:54to ready to here to really hear what,
01:10:57how pervasive and what the extent
01:11:00of structural racism has been.
01:11:02So, I mean, we can point to examples of it,
01:11:06but really, understanding the
01:11:08entire T of it is going to take.
01:11:12A long time and a lot of work and
01:11:14I don't know how from where I sit
01:11:18right now to begin to dis entangle.
01:11:21Epigenetics are from structural
01:11:22racism per say.
01:11:23It's going to have to be attention to detail,
01:11:26attention to the subtlety Anna lot of
01:11:29thought about how you structure your
01:11:31analysis, an what data set you're using,
01:11:33and how you handle that data set.
01:11:36It's a great question, but I don't.
01:11:39I don't know that.
01:11:41I mean there's like that.
01:11:43That literature is growing so
01:11:45rapidly and it's so bulky to be
01:11:48able to delve into it process it,
01:11:50synthesize it, and then take.
01:11:53From that What you want to apply to inform?
01:11:59Analysis about epigenetics.
01:12:01It's monumental undertaking.
01:12:04Here's
01:12:05a question. I think you that you
01:12:07you're talking touched on to some
01:12:09point in answer to some extent,
01:12:11but but I'm curious on your thoughts on this.
01:12:14Do you think poverty and low income are
01:12:16the underlying causes of the disparities?
01:12:18Now you based on my understanding,
01:12:20you pointed out that if you control for
01:12:22income that you still see the disparity.
01:12:25But there was an interesting aspect of
01:12:27this question which is. For example,
01:12:29microbiome is influenced by environment,
01:12:30the diet, stress etc,
01:12:32and those who experience poverty
01:12:33are impacted tremendously.
01:12:34But if poverty caused by structural racism.
01:12:37Then we need to address racism as well.
01:12:39Question mark,
01:12:40but you're saying that poverty
01:12:42if you control for poverty you
01:12:44still see the difference.
01:12:45I am and this is. This is kind of a.
01:12:49A tricky question, and when we
01:12:52begin to see how everything is so.
01:12:54Intertwined and I guess that really
01:12:58what really what I'm saying is
01:13:01from where we stand right now.
01:13:04I wouldn't discount anything.
01:13:05I think that's really the message
01:13:08that I wanted to get across is.
01:13:13I yeah. I wouldn't discount anything.
01:13:18I think that that all of these
01:13:20approaches are legitimate possibilities.
01:13:22But to Opry Ori say no,
01:13:23it can't be one thing.
01:13:25It can only be the other thing I think is
01:13:27is a disservice is doing a disservice.
01:13:30Well, I appreciate.
01:13:31I appreciate that sentiment in
01:13:32particular. It may be 'cause I actually
01:13:34had written down some questions as we
01:13:36went along in the talk was so nice
01:13:39that as you went along you answered
01:13:40my questions and stuff, you know.
01:13:42But when I wanted to talk about
01:13:44one of my questions was is there
01:13:46actually a political price?
01:13:48For endorsing or not endorsing a potential
01:13:51genetic role in disparities and I,
01:13:55I think that you've kind of.
01:13:59Well, I'll ask,
01:13:59ask you to speak to that because I
01:14:02think that you imply that there are
01:14:04some people who feel stronger than
01:14:06we shouldn't go in that direction
01:14:08for all the reasons you talked about.
01:14:10And by the way,
01:14:11the history of eugenics in medicine
01:14:13is not a subtle one.
01:14:14In New Haven's role and major
01:14:16academic institutions all over,
01:14:17including Yale's role in eugenics in
01:14:19the earlier part of the 20th century.
01:14:21In we carry this legacy with
01:14:23us as physicians,
01:14:24unfortunately,
01:14:24and his academics so that that
01:14:26caution is certainly there.
01:14:27But your message seems to be.
01:14:29Let's keep every door open and let's
01:14:31look everywhere we can amass strikes me
01:14:34as as as as something that strikes me.
01:14:37Amerson, you concomitant,
01:14:38you seem less married to a specific answer
01:14:41then you are to solving the problem.
01:14:43I agree,
01:14:44I think that in my in my short career
01:14:47just reading and talking and networking
01:14:50and being exposed to all different ideas
01:14:53in many different contexts has I can.
01:14:56I can see how it shifted and
01:14:59refined my view. And so I I.
01:15:02I come to this question with thoughts
01:15:04about how I'd like to investigate it.
01:15:08An roads I'd like to go down,
01:15:11but there's so many twists and turns
01:15:13and it's so complex. That I think.
01:15:18Said saying at the outset,
01:15:19this is what it must be.
01:15:22An I reject everything else has the
01:15:24has the potential to actually further
01:15:27undermine and hurt the very people that
01:15:30you're trying to help by excluding
01:15:33them from potentially benefiting from
01:15:35something like I think about it in a
01:15:38similar way to the lack of inclusion
01:15:42of African American folks in clinical
01:15:44trials in vaccine trials like it.
01:15:47In my mind,
01:15:48it seems very clear that there was.
01:15:52Kind of a dual mistrusted
01:15:54the medical institution,
01:15:56but also maybe not wanting to two.
01:15:59Go out of one's way to bring in members
01:16:02from this group that has a history
01:16:05of being a manipulated by or taken
01:16:09advantage of by the medical establishment.
01:16:12They were not included and therefore
01:16:14did not have the opportunity to.
01:16:17Benefit from discoveries that
01:16:19may have been made.
01:16:20So I'm not saying that's what would happen,
01:16:23but that's that's my worry
01:16:25that if we say upfront,
01:16:27no,
01:16:27this can't be that you have denied the
01:16:30opportunity to benefit from something.
01:16:32If it turns out to be there.
01:16:36Thank you. Another question, please,
01:16:38are you aware of quality improvement
01:16:41initiatives or other interventions
01:16:42that have shown the ability to narrow
01:16:45the disparities in maternal neonate?
01:16:46Allowed comma and black women?
01:16:48Better access to care, etc.
01:16:50Are you aware of research that looks
01:16:52specifically at adverse childhood
01:16:54events and racial disparities in
01:16:56maternal neonatal outcomes? So two
01:16:58somewhat different questions,
01:16:59so I am aware of broadly research in
01:17:03both of those domains because it's.
01:17:05That's not the space that I work in as much.
01:17:09I haven't really been in.
01:17:12An exploring that literature recently.
01:17:14But there's certain there certainly
01:17:16is a robust literature about
01:17:18average early childhood experiences,
01:17:20aces, and how those experiences
01:17:22can drive disparities,
01:17:23and in terms of interventions.
01:17:26I come across them as I'm kind of
01:17:29looking for articles on other topics,
01:17:32so I know that certainly they do exist,
01:17:35and there have been some.
01:17:37Strides need an people are
01:17:39putting their work out there so
01:17:42you know that that does exist,
01:17:44but it hasn't been in kind of a.
01:17:48A sweeping manner that's been able to
01:17:53kind of infiltrate on a national scale.
01:17:58Practice patterns.
01:18:00Here's
01:18:01a provocative.
01:18:03Point that must be raised.
01:18:07Door we didn't open.
01:18:08We talked about leaving all the
01:18:10doors open to try and get to the
01:18:11answer to make things better.
01:18:13The door we didn't open was
01:18:15physician behavior in practice,
01:18:17and that's the one thing
01:18:18we can always control.
01:18:20We really perpetuated a lack
01:18:22of physician accountability.
01:18:24To a group of learning
01:18:25medical providers no less.
01:18:26That's the common on this thing,
01:18:28so a lack of position to kind of.
01:18:30I don't know if that's been perpetuate it,
01:18:33but I have to say I
01:18:35found this traumatizing.
01:18:36Do you want to comment on that?
01:18:40What was traumatizing, I'm sorry, well I get
01:18:42the sense from the from the from the
01:18:45question that that the concern here
01:18:47was that we didn't talk about physician
01:18:49accountability and that this is this is
01:18:51this has been raised but we didn't talk
01:18:54specifically about what there may be
01:18:56a physician's role in this disparity,
01:18:58because as I know you know well,
01:19:01amorous that there have been studies
01:19:03that show that even among those that
01:19:05are quite sure we're doing it right.
01:19:07In fact, we're not.
01:19:08Can not always everyone all the time,
01:19:11but in fact there are certainly disparities
01:19:13in the way we care for patients.
01:19:15Do you do you want to comment on
01:19:18how physician action activity may?
01:19:21Be impacting that disparity specifically
01:19:23in maternal and neonatal outcomes.
01:19:27So it is always a challenge because I think.
01:19:33In the. Nick, you it can feel like we have.
01:19:38More control over the immediate
01:19:41environment of the patient
01:19:42because they were there with us.
01:19:45And we don't. Necessarily recognize
01:19:50in ourselves when perhaps we are
01:19:55perpetuating some of the disparities.
01:19:58I guess I'm not really.
01:20:00I mean, it's it's true, it is.
01:20:02It is a huge.
01:20:07It is a topic that is right for
01:20:10discussion that needs to be discussed
01:20:12and should be incorporated.
01:20:13I will say I didn't really incorporate it
01:20:16into this conversation as much because I.
01:20:19I'm thinking more at the
01:20:23population level and it's very.
01:20:27If it's a challenging.
01:20:30It's a challenging realization to
01:20:33have that you may be perpetuate ING.
01:20:36Stereotypes in situations where.
01:20:42You're propagating disparities,
01:20:44but I'm not. I guess I don't really
01:20:48know what to say.
01:20:49I know I appreciate that Emerson.
01:20:51I appreciate that went through a lot
01:20:53of things and you didn't you didn't.
01:20:55You didn't in this talk at the cover,
01:20:58every possible aspect of this,
01:20:59but there was an awful lot
01:21:01of things that were covered,
01:21:03but certainly our role as physicians,
01:21:04our complicity as physicians,
01:21:06and perhaps contributing to those
01:21:08disparities are something we need to look at.
01:21:10And this is where again,
01:21:11I think the comparison to other
01:21:13countries where perhaps the racism is.
01:21:15And other settings where racism is different,
01:21:17perhaps less, perhaps more.
01:21:18How all these things could compare
01:21:20to see to see how we do this.
01:21:22Again, I think the ultimate goal,
01:21:24and I appreciate the sentiment
01:21:25you're trying to do is to try and
01:21:28find out what's causing the problem
01:21:29so that you can make it better.
01:21:31You and a lot of other smart
01:21:33people trying to sort this out,
01:21:35and no doubt I shouldn't say no doubt.
01:21:38I think most of us would agree that
01:21:40physician behavior is certainly
01:21:41part of the problem.
01:21:42And this is something that we
01:21:44have to keep our eyes open to
01:21:46another question please,
01:21:48I'm wondering if you can comment on the
01:21:50relationship between low birth weight,
01:21:52preterm birth and racism,
01:21:53i.e.
01:21:54Through mechanisms like increased cortisol,
01:21:55are there studies that have looked at
01:21:58perceived racism and how that itself
01:22:00is associated with low birth weight?
01:22:03So there are studies that have looked at
01:22:06that the results are somewhat conflicting.
01:22:10Ann are not the most robust.
01:22:14I think some of the more
01:22:18interesting studies have looked at.
01:22:21Have looked at women who underwent.
01:22:23I'd like a an acute stressor during
01:22:26the pregnancy and then followed them
01:22:29to see what happened with their
01:22:32babies and there was an increased.
01:22:35Risk or rate of very low birth weight.
01:22:38I'm thinking specifically about
01:22:40kind of a cross sectional study that
01:22:43was done in Iowa before an after.
01:22:46I believe it was an ice raid for to look
01:22:49for illegal immigrants and deport them,
01:22:53and they looked at.
01:22:55They looked at the at the.
01:22:58Rate of low birth weight,
01:23:00kind of in the year before that
01:23:02happened and then in the nine
01:23:04months to a year after that happened
01:23:07in compared between the two.
01:23:09But in terms of in terms of.
01:23:14That that relationship with.
01:23:17With how with experienced racism,
01:23:20it's it's often self report.
01:23:22I just have I think that we that
01:23:24we are still struggling to find a
01:23:27good measurement measurement tool
01:23:30that's more accurate and reliable.
01:23:32But the court,
01:23:34like the correlation doesn't
01:23:36is not that robust.
01:23:38From the few studies I've seen.
01:23:41There are
01:23:41a couple other questions which
01:23:42are interesting which I'm not
01:23:44going to have time to get to,
01:23:45but I'm going to encourage the people
01:23:47who ask him one related to the potential
01:23:48role of doulas in reducing stress is
01:23:50another about policy actions that you
01:23:52might recommend so I would I would
01:23:53ask those individuals if you send
01:23:55something to me through that website.
01:23:56I mentioned to biomedical ethics at Yale,
01:23:58I'm if you reach out to that
01:24:00to Karen who's our manager.
01:24:01I'll see that these questions get
01:24:03to Doctor Kaiser and if you have
01:24:04a minute or two to think about
01:24:06it to respond to an email.
01:24:07If you want amorous but I knew I
01:24:09wouldn't be able to get everything and
01:24:11now we only have a minute or two left.
01:24:13But I want to leave it with a
01:24:15chance for you to share with us.
01:24:17Any final thoughts you have any
01:24:19suggestions you have about the
01:24:22direction this work should go?
01:24:24I want you to just.
01:24:25We've got just a minute or two left.
01:24:27I want you to have the final word on
01:24:28this on whatever topic you want to.
01:24:30However you want to address the topic.
01:24:32I think it's a.
01:24:34It's a hard topic there.
01:24:37Challenging conversations to have.
01:24:38It's really exciting because
01:24:40of the opportunity to work in,
01:24:43uh, in multidisciplinary teams.
01:24:45This problem. This issue is so complex.
01:24:48It's so multi layered everything is
01:24:51so entangled that you really need.
01:24:54Awareness of the research and the
01:24:58ideas that are being discussed in
01:25:02other realms outside of the hospital.
01:25:06That that will enrich the work,
01:25:08but I guess what I'm left with
01:25:11is the importance,
01:25:12the necessity of working in teams
01:25:14so that you can amass the team.
01:25:16That's going to have the expertise
01:25:18to be able to delve into all of
01:25:21these different realms and begin
01:25:23to make sense of all of it,
01:25:25and to make sense of how it fits together
01:25:28so that we understand where we go next.
01:25:32Thank
01:25:33you very much Doctor,
01:25:34Amorous casual this has been an
01:25:36extraordinary 90 minutes and we're
01:25:38very grateful for your time and your
01:25:40expertise and we look forward to your
01:25:42next visit in person back home to Yale.
01:25:45Thank you all very much for attending an.
01:25:48We're getting nice comments
01:25:49here from folks who very much
01:25:51appreciate the talk amorous I owe
01:25:53you 1 this was terrific. Thank you
01:25:56so much. Goodnight folks. Here.