Christine H. Morton, PhD is a medical sociologist with expertise in maternal mortality and morbidity, women's reproductive and maternal health experiences and maternal quality improvement. Since 2008, she has managed CMQCC's state funded project on California Pregnancy-Associated Maternal Review (CA-PAMR), overseeing data collection, committee matters and conducting qualitative analysis on improvement opportunities identified from case reviews. She served as co-chair of the CMQCC Cardiovascular Disease in Pregnancy and Postpartum Taskforce, coordinating the development of a Maternal Quality Toolkit on this leading cause of maternal death in California. She also collaborates on research projects that support CMQCC’s goals and mission, including an interview study of women's experiences with severe maternal morbidity and collaborative research with Dr. Jochen Profit on racial/ethnic disparities in Neonatal Intensive Care. Dr. Morton is co-chair of the National Partnership Maternal Safety workgroup on Patient, Family and Staff Support after a Severe Maternal Event and now chairs the Research Work Group for Lamaze International after serving a four-year term on the Board of Directors.
Current Role at Stanford
Research Sociologist and Program Manager at California Maternal Quality Care Collaborative (CMQCC)
Education & Certifications
PhD, UCLA, Sociology (2002)
Maternal Mortality and Morbidity, Preeclampsia, Cardiovascular Disease, Quality Measurement, Quality Improvement, Childbirth and Pregnancy, Qualitative Methods
Bearing witness: United States and Canadian maternity support workers' observations of disrespectful care in childbirth
BIRTH-ISSUES IN PERINATAL CARE
2018; 45 (3): 263–74
Disrespectful care and abuse during childbirth are acknowledged global indicators of poor quality care. This study aimed to compare birth doulas' and labor and delivery nurses' reports of witnessing disrespectful care in the United States and Canada.Maternity Support Survey data (2781 respondents) were used to investigate doulas' and nurses' reports of witnessing six types of disrespectful care. Multivariate analysis was conducted to examine the effects of demographics, practice characteristics, region, and hospital policies on witnessing disrespectful care.Nearly two-thirds of respondents reported witnessing providers occasionally or often engaging in procedures without giving a woman time or option to consider them. One-fifth reported witnessing providers occasionally or often engaging in procedures explicitly against the patient's wishes, and nurses were more likely to report witnessing this than doulas. Doulas and nurses who expected to leave their job within three years were significantly more likely to report that they witness most types of disrespectful care occasionally or often (OR 1.78-2.43).Doulas and nurses frequently said that they witnessed verbal abuse in the form of threats to the baby's life unless the woman agreed to a procedure, and failure to provide informed consent. Reports of witnessing some types of disrespectful care in childbirth were relatively uncommon among respondents, but witnessing disrespectful care was associated with an increased likelihood to leave maternity support work within three years, raising implications for the sustainability of doula practice, nursing work force shortages, and quality of maternity care overall.
View details for DOI 10.1111/birt.12373
View details for Web of Science ID 000441423800007
View details for PubMedID 30058157
Recent Increases in the U.S. Maternal Mortality Rate: Disentangling Trends From Measurement Issues.
Obstetrics and gynecology
2016; 128 (3): 447–55
To develop methods for trend analysis of vital statistics maternal mortality data, taking into account changes in pregnancy question formats over time and between states, and to provide an overview of U.S. maternal mortality trends from 2000 to 2014.This observational study analyzed vital statistics maternal mortality data from all U.S. states in relation to the format and year of adoption of the pregnancy question. Correction factors were developed to adjust data from before the standard pregnancy question was adopted to promote accurate trend analysis. Joinpoint regression was used to analyze trends for groups of states with similar pregnancy questions.The estimated maternal mortality rate (per 100,000 live births) for 48 states and Washington, DC (excluding California and Texas, analyzed separately) increased by 26.6%, from 18.8 in 2000 to 23.8 in 2014. California showed a declining trend, whereas Texas had a sudden increase in 2011-2012. Analysis of the measurement change suggests that U.S. rates in the early 2000s were higher than previously reported.Despite the United Nations Millennium Development Goal for a 75% reduction in maternal mortality by 2015, the estimated maternal mortality rate for 48 states and Washington, DC, increased from 2000 to 2014; the international trend was in the opposite direction. There is a need to redouble efforts to prevent maternal deaths and improve maternity care for the 4 million U.S. women giving birth each year.
View details for DOI 10.1097/AOG.0000000000001556
View details for PubMedID 27500333
Never judge a book by its cover: how NICU evaluators reach conclusions about quality of care.
Journal of perinatology : official journal of the California Perinatal Association
OBJECTIVE: To identify key features in the NICU care delivery context that influence quality of care delivery.STUDY DESIGN: Qualitative study using in-depth, semi-structured interviews with 10 NICU quality experts with extensive experience conducting NICU site visits and evaluating quality of care. Analyses were performed using the method of constant comparison based on grounded theory.RESULTS: Qualitative analysis yielded three major themes: (1) the foundation for high quality care is a cohesive unit culture, characterized by open communication, teamwork, and engagement of families; (2) effective linkages between measurement and improvement action is necessary for continuous improvement; and (3) NICU capacity for improvement is sustained by active support, exchange of skills, and resources from the hospital.CONCLUSIONS: Team cohesion, engagement of families, culture of improvement supported by measurement and institutional support from the hospital are some of the key contextual and managerial features critical to high-quality NICU care.
View details for DOI 10.1038/s41372-018-0092-0
View details for PubMedID 29593356
Disparities in NICU quality of care: a qualitative study of family and clinician accounts.
Journal of perinatology : official journal of the California Perinatal Association
To identify how family advocates and clinicians describe disparities in NICU quality of care in narrative accounts.Qualitative analysis of a survey requesting disparity stories at the 2016 VON Quality Congress. Accounts (324) were from a sample of RNs (n = 114, 35%), MDs (n = 109, 34%), NNPs (n = 55, 17%), RN other (n = 4, 1%), clinical other (n = 25, 7%), family advocates (n = 16, 5%), and unspecified (n = 1, <1%).Accounts (324) addressed non-exclusive disparities: 151 (47%) language; 97 (30%) culture or ethnicity; 72 (22%) race; 41 (13%) SES; 28 (8%) drug use; 18 (5%) immigration status or nationality; 16 (4%) sexual orientation or family status; 14 (4%) gender; 10 (3%) disability. We identified three types of disparate care: neglectful care 85 (26%), judgmental care 85 (26%), or systemic barriers to care 139 (44%).Nearly all accounts described differential care toward families, suggesting the lack of equitable family-centered care.
View details for DOI 10.1038/s41372-018-0057-3
View details for PubMedID 29622778
North American Nurses' and Doulas' Views of Each Other.
Journal of obstetric, gynecologic, and neonatal nursing : JOGNN
To analyze factors that lead nurses and doulas to have positive views of each other.A multivariate analysis of a cross-sectional survey, the Maternity Support Survey.Online survey with labor and delivery nurses, doulas, and childbirth educators in the United States and Canada.A convenience sample of 704 labor and delivery nurses and 1,470 doulas.Multiple regression analysis was used to examine five sets of hypotheses about nurses' and doulas' attitudes toward each other. Scales of nurses' attitudes toward doulas and doulas' attitudes toward nurses included beliefs that nurses/doulas enhance communication, are collaborative team members, enhance a woman's birth experience, interfere with the ability to provide care, or interfere with relationships with the women for whom they care.For nurses, exposure to doulas in their primary hospitals was associated with more positive views, whereas working more hours, feeling overworked, and a preference for clinical tasks over labor support were associated with more negative views of doulas. For doulas, working primarily in one hospital and certification were associated with more positive views of nurses. Nurses with more positive attitudes toward common obstetric practices had more negative attitudes toward doulas, whereas doulas with more positive attitudes toward common obstetric practices had more positive attitudes toward nurses.Our findings show factors that influence mutual understanding and appreciation of nurses and doulas for each other. These factors can be influenced by educational efforts to improve interprofessional collaboration between these maternity care support roles.
View details for DOI 10.1016/j.jogn.2016.06.011
View details for PubMedID 27622848
Women's Experiences Being Diagnosed With Peripartum Cardiomyopathy: A Qualitative Study.
Journal of midwifery & women's health
2016; 61 (4): 467-473
Cardiovascular disease has been identified as the leading cause of maternal mortality in the United States, with cardiomyopathy, including peripartum cardiomyopathy (PPCM), accounting for 12% to 16% of all pregnancy-related deaths. The purpose of this study was to describe women's experiences being diagnosed with PPCM.This investigation was conducted using a qualitative design. We collected publicly available narratives posted by 92 women with PPCM (mean [SD] age 29  years, mean [SD] ejection fraction 25.5 [10.8]%) in 3 online support groups. Data were coded and thematically organized so as to produce a richly detailed account of this experience.The experience of diagnosis was marked by the women's distinct memories of their initial symptoms and whether they were dismissed or taken seriously. The most commonly reported symptoms were extreme shortness of breath, orthopnea, tachycardia, palpitations, chest pain, cough, and edema. Nearly 40% of women experienced symptom dismissal by health care providers. One-fourth of women were initially given inaccurate diagnoses ranging from "new mom anxiety" to asthma. Women described their initial reaction to diagnosis as feeling terrified, devastated, and feeling a sense of doom. Women had difficulty caring for their newborns during the postpartum period, and they struggled with the medical advice they received to not get pregnant again.Despite experiencing severe subjective and objective symptoms, nearly 40% of women with PPCM experienced symptom dismissal by health care providers, in part due to the overlap between normal symptoms of pregnancy or the postpartum period and symptoms of heart failure.
View details for DOI 10.1111/jmwh.12448
View details for PubMedID 27285199
Race, Insurance Status, and Nulliparous, Term, Singleton, Vertex Cesarean Indication: A Case Study of a New England Tertiary Hospital
WOMENS HEALTH ISSUES
2016; 26 (3): 329-335
The current U.S. cesarean section rate (32.2%) is recognized as too high in light of its negative health impacts on women and infants. Efforts are underway in several states and individual hospitals to lower the rate of cesarean section among low-risk women, defined as nulliparous (first birth), term (≥37 weeks gestation), singleton (one baby), vertex (head down presentation; NTSV).We conducted a case study of one hospital's experience with NTSV cesarean sections to see whether race and insurance status affect the probability of cesarean indication. Many cesarean indications are ambiguous, and biases may seep into decisions with ambiguous diagnoses.We conducted a retrospective chart review of women who had NTSV cesarean sections at a tertiary care hospital in an urban New England city between June 2013 and November 2013. We analyzed the data using multinomial logistic regression to examine the marginal effect of race and health insurance status on the predicted probability for NTSV cesarean indication.We find that Black and Hispanic women have a lower predicted probability of having a cesarean section for cephalopelvic disproportion than do White women and that women with private health insurance have a lower predicted probability of having a cesarean section for nonreassuring fetal heart rate and for a clinical indication than do women without private health insurance.We suggest biases may seep into clinicians' decisions to perform an NTSV cesarean section. Hospital quality improvement efforts are aided by an examination of sociodemographic factors that influence clinician decision making in the specific hospital being studied.
View details for DOI 10.1016/j.whi.2016.02.005
View details for Web of Science ID 000379739500012
View details for PubMedID 27017294
Pregnancy-Related Mortality in California Causes, Characteristics, and Improvement Opportunities
OBSTETRICS AND GYNECOLOGY
2015; 125 (4): 938-947
To compare specific maternal and clinical characteristics and contributing factors among the five leading causes of pregnancy-related mortality to develop focused clinical and public health prevention programs.California pregnancy-related deaths from 2002-2005 were identified with enhanced surveillance using linked birth and death certificates. A multidisciplinary committee reviewed medical records, autopsy reports, and coroner reports to determine cause of death, clinical and demographic characteristics, chance to alter outcome, contributing factors (at health care provider, facility, and patient levels), and quality improvement opportunities. The five leading causes of death were compared with each other and with the overall California birth population.Among the 207 pregnancy-related deaths, the five leading causes were cardiovascular disease, preeclampsia or eclampsia, hemorrhage, venous thromboembolism, and amniotic fluid embolism. Among the leading causes of death, we identified differing patterns for race, maternal age, body mass index, timing of death, and method of delivery. Overall, there was a good-to-strong chance to alter the outcome in 41% of deaths, with the highest rates of preventability among hemorrhage (70%) and preeclampsia (60%) deaths. Health care provider, facility, and patient contributing factors also varied by cause of death.Pregnancy-related mortality should not be considered a single clinical entity. Reducing mortality requires in-depth examination of individual causes of death. The five leading causes exhibit different characteristics, degrees of preventability, and contributing factors, with the greatest improvement opportunities identified for hemorrhage and preeclampsia. These findings provide additional support for hospital, state, and national maternal safety programs.
View details for DOI 10.1097/AOG.0000000000000746
View details for Web of Science ID 000351595200026
View details for PubMedID 25751214
Pregnancy-related cardiovascular deaths in California: beyond peripartum cardiomyopathy.
American journal of obstetrics and gynecology
Maternal mortality rates rose markedly from 2002 to 2006 in California, prompting an in-depth maternal mortality review in a state that comprises one twelfth of the US birth cohort. Cardiovascular disease has emerged as the leading cause of pregnancy-related death in the United States. The primary aim of this analysis was to describe the incidence and type of cardiovascular disease as a cause of pregnancy-related mortality in California. The secondary aims were to describe racial/ethnic and socioeconomic disparities, risk factors, birth outcomes, timing of death and diagnosis, and signs and symptoms of cardiovascular disease and identify contributing factors.The California Pregnancy-Associated Mortality Review retrospectively examined a case series of 64 cardiovascular pregnancy-related deaths from 2002 through 2006. Two cardiologists independently reviewed complete inpatient and outpatient medical records including laboratory, radiology, electrocardiogram, chest X-ray, echocardiograms, and autopsy findings for each cardiovascular death and classified cause of death by type of cardiovascular disease. Demographic data, racial disparities, risk factors, signs and symptoms, timing of diagnosis and death, birth outcomes, and contributing factors were analyzed using bivariate comparisons with noncardiovascular pregnancy-related deaths and population-based data.Among 2,741,220 California women who gave birth, 864 died while pregnant or within 1 year of pregnancy; 257 of the deaths were deemed pregnancy related, and of these, 64 (25%) were attributed to cardiovascular disease. There were 42 deaths caused by cardiomyopathy, and the pregnancy-related mortality rate from cardiomyopathy was 1.54 per 100,000 births. Dilated cardiomyopathy existed in 29 cases, of which 15 met the definition of peripartum cardiomyopathy. Women with cardiovascular disease were more likely than women who died from noncardiovascular causes to be African-American (39.1% vs 16.1%; P < .01) and more likely to use illicit substances (23.7% vs 9.4%; P < .01). Thirty-seven percent were obese and 20% had a concomitant diagnosis of hypertension or preeclampsia during pregnancy. Health care decisions in the diagnosis or treatment of cardiovascular disease during and after pregnancy contributed to the fatal outcomes.African-American race, substance use, and obesity were risk factors for pregnancy-related cardiovascular disease mortality. Chronic disease prevention and better recognition and response to cardiovascular disease during pregnancy are needed to reduce maternal mortality.
View details for DOI 10.1016/j.ajog.2015.05.008
View details for PubMedID 25979616
- The Problem of Increasing Maternal Morbidity: Integrating Normality and Risk in Maternity Care in the United States BIRTH-ISSUES IN PERINATAL CARE 2014; 41 (2): 119-121
California Pregnancy-Associated Mortality Review: Mixed Methods Approach for Improved Case Identification, Cause of Death Analyses and Translation of Findings
MATERNAL AND CHILD HEALTH JOURNAL
2014; 18 (3): 518-526
After several decades of declining rates, maternal mortality climbed in California from a three-year moving average of 9.4 deaths per 100,000 live births in 1999-2001 to a high of 14.0 deaths per 100,000 live births in 2006-2008 (p < 0.001). The Maternal, Child and Adolescent Health Division of the California Department of Public Health developed a mixed method approach to identify and investigate maternal deaths to inform prevention strategies. This paper describes the methodology of the California Pregnancy-Associated Mortality Review (CA-PAMR) and its advantages for improved surveillance, cause of death analysis, and translation of findings. From 2002 to 2004, 1,598,792 live births occurred in California and 555 women died while pregnant or within one year of pregnancy. A screening algorithm identified cases for review that were likely to be pregnancy-related. Medical records were then abstracted and reviewed by a multidisciplinary committee to determine cause of death, contributing factors, and opportunities for quality improvement. Mixed methods were used to analyze, synthesize and translate Committee recommendations for improved care. Of 211 cases selected for review, 145 deaths were determined to be pregnancy-related. CA-PAMR methods corrected misclassification of cases and more accurately identified the leading causes of death. Cardiovascular disease emerged as the leading cause of pregnancy-related deaths (20%), and African-American women were disproportionately represented among cardiovascular deaths. Overall, the chance to prevent the fatal outcome appeared good or strong in 40% of cases reviewed. The CA-PAMR methodology resulted in additional case finding, improved accuracy of the causes of pregnancy-related deaths, and evidence to guide development of prevention and quality improvement efforts.
View details for DOI 10.1007/s10995-013-1267-0
View details for Web of Science ID 000333026600002
View details for PubMedID 23584929
- California Pregnancy-Associated Mortality Review: Mixed methods approach for improved case identification, cause of death analyses and translation of findings Maternal Child Health Journal 2013
Creating a Public Agenda for Maternity Safety and Quality in Cesarean Delivery
OBSTETRICS AND GYNECOLOGY
2012; 120 (5): 1194-1198
Cesarean delivery rates in California and the United States rose by 50% between 1998 and 2008 and vary widely among states, regions, hospitals, and health care providers. The leading driver of both the rise and the variation is first-birth cesarean deliveries performed during labor. With the large increase in primary cesarean deliveries, repeat cesarean delivery now has emerged as the largest single indication. The economic costs, health risks, and negligible benefits for most mothers and newborns of these higher rates point to the urgent need for a new approach to working with women in labor. This commentary analyzes the high rates and wide variations and presents evidence of costs and risks associated with cesarean deliveries (complete discussion provided in the California Maternal Quality Care Collaborative White Paper at www.cmqcc.org/white_paper). All stakeholders need to ask whether society can afford the costs and complications of this high cesarean delivery rate and whether they can work together toward solutions. The factors involved in the rise in cesarean deliveries point to the need for a multistrategy approach, because no single strategy is likely to be effective or lead to sustained change. We outline complementary strategies for reducing the rates and offer recommendations including clinical improvement strategies with careful examination of labor management practices; payment reform to eliminate negative or perverse incentives; education to recognize the value of vaginal birth; and full transparency through public reporting and continued public engagement.
View details for DOI 10.1097/AOG.0b013e31826fc13d
View details for Web of Science ID 000310512500027
View details for PubMedID 23090538
- Standardising or individualising?: A critical analysis of the 'discursive imaginaries' shaping maternity care reform International Journal of Childbirth 2012; 2 (3): 173-186
- Safety in childbirth and the three ‘C’s: community, context, and culture Midwifery 2010; 26: 481-482