Two years ago, the Office of the Surgeon General published its Call to Action to Improve Maternal Health. That document noted that despite access to world-class medical care, the maternal mortality rate in the United States was higher than that of countries that are similarly technologically advanced. The report called racial and ethnic disparities “especially concerning” and called for evidence-based measures to be put in place. In keeping with this urgent request, researchers from the Columbia University Vagelos College of Physicians and Surgeons set out to explore the impact a diverse registered nurse workforce has on maternal health outcomes. They concluded that “A diverse state registered nurse workforce is associated with reduced risk of severe adverse maternal outcomes during childbirth.”
Main points:
- Racial and ethnic diversity in a state’s registered nurse workforce is associated with reduced risk of severe adverse maternal outcomes
- Diversifying the registered nurse workforce may significantly reduce racial and ethnic disparities in maternal health outcomes
- The study used 2017 U.S. birth certificate data, identifying how many births in each state included a severe adverse maternal outcome and comparing that number to the proportion of that state’s nurses that were racially and ethnically diverse.
What did the report say about diversity and health outcomes?
The researchers investigated whether there was a link between the number of mothers who had suffered severe adverse maternal outcomes — defined as eclampsia, blood transfusion, hysterectomy and intensive care admission — to the diversity of their states’ nursing workforce. They also categorized mothers who had suffered these outcomes by their race.
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What they found was that there was a significant difference between the number of severe adverse maternal outcomes in the states with the lowest level of diversity in its workforce and those with the greatest. By mother’s race, the researchers found that the incidence of severe adverse maternal outcomes was:
- White mothers: 85.3 per 10,000 in states in the first tercile and 53.9 per 10,000 for those in states in the third tercile
- Black mothers: 130.6 per 10,000 in states in the first tercile and 85.7 per 10,000 for those in states in the third tercile
- Hispanic mothers: 100.3 per 10,000 in states in the first tercile and 51.1 per 10,000 for those in states in the third tercile
- Asian and Pacific Islander mothers: 96.0 per 10,000 in states in the first tercile and 62.9 for those in states in the third tercile.
After correcting the data for patients and hospital characteristics, the researchers concluded that for white mothers, delivering in states in the third tercile of registered nurse diversity yielded a 32% reduced risk of severe adverse outcomes, while for Black, Hispanic, and Asian and Pacific Islander mothers the reduction was 20%, 31%, and 50% respectively.
The significance of the report’s findings
The study’s authors emphasized the actions that could be taken as a result of their findings. Guohua Li, MD, DrPH, professor of epidemiology and anesthesiology at Columbia Mailman School and VP&S said, “This study is important because persistent racial disparities in maternal morbidity and mortality are of public health significance and because health care workforce diversity is amenable to policy interventions. He pointed to the advantages to be gained by increasing minority representation in nurses, saying, “Demographic diversity is widely regarded as a strength of the United States. Our study indicates that workforce diversity could also be a major strength of the U.S. health system, which benefits the entire population.”
First author Jean Guglielmiotti, MD, Ph, in the Department of Anesthesiology noted that “Structural racism in public policies, institutional practices, cultural representations, and other norms works to perpetuate racial group inequities and what we believe contributes to these disparities in severe adverse maternal outcomes, independent of poverty and other social determinants of health,” with black and Native Americans at the greatest risk.
While noting that their findings “hold up for white mothers as well as for mothers of color,” Li added that the study demonstrates that a more diverse nurse workforce could help to “reduce provider implicit bias and enhance communications and trust between patients and clinicians.” to diversify the workforce with the goal of addressing racial and ethnic disparities.
How did they do the study?
The researchers used the American Community Survey’s 5-year estimate from the years 2013-2017 to identify the proportion of minoritized racial and ethnic nurses in each state. They divided each state into thirds in which the first third had the lowest proportion of diverse registered nurses, ranging for 3.3-14 percent, and the third had the highest proportion with ranges of between 32 and 68 percent. They then used 2017 U.S. Birth Certificate data to determine that out of 3,668,813 birth certificates included in the study, 29,174 (or 0.8 percent) recorded severe adverse maternal outcomes, identified as eclampsia, blood transfusion, hysterectomy, or intensive care unit admission.
The highest incidence of severe maternal adverse effects were identified as occurring among Native American mothers (1.75 percent), with Black mothers next at 1 percent, mothers of more than one race also at 1 percent, white mothers at 0.74 percent, Asian/Pacific Islander mothers at 0.73 percent, and Hispanic mothers at 0.7 percent.
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Sources
- “Nurse workforce diversity and reduced risk of severe adverse maternal outcomes.”
- ajogmfm.org. Accessed July 23, 2022.
- “Diverse Nurse Workforce Linked to Better Maternal Health Outcomes in Childbirth.”
- publichealth.columbia.edu. Accessed July 23, 2022.
- “American Community Survey.” Census.gov. Accessed July 23, 2022.
- “Nurse diversity linked to a reduced risk of maternal health issues, study finds.” nbcnews.com. Accessed July 26, 2022.
- “The Surgeon General’s Call to Action to Improve Maternal Health.” U.S. Department of Health and Human Services. Accessed July 23, 2022.
