Bio

Bio


Christine Morton is a medical sociologist with expertise in women's reproductive 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 an analysis of women's online peripartum cardiomyopathy narratives. Dr. Morton is a member of the National Partnership Maternal Safety workgroup on Patient, Family and Staff Support after a Severe Maternal Event and serves on the Board of Directors of Lamaze International.

Current Role at Stanford


Research Sociologist and Program Manager at California Maternal Quality Care Collaborative (CMQCC)

Education & Certifications


  • PhD, UCLA, Sociology (2002)

Professional

Professional Interests


Maternal Mortality and Morbidity, Preeclampsia, Cardiovascular Disease, Quality Measurement, Quality Improvement, Childbirth and Pregnancy, Qualitative Methods

Publications

All Publications


  • Recent Increases in the U.S. Maternal Mortality Rate: Disentangling Trends From Measurement Issues. Obstetrics and gynecology MacDorman, M. F., Declercq, E., Cabral, H., Morton, C. 2016; 128 (3): 447-55

    Abstract

    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

  • Women's Experiences Being Diagnosed With Peripartum Cardiomyopathy: A Qualitative Study. Journal of midwifery & women's health Dekker, R. L., Morton, C. H., Singleton, P., Lyndon, A. 2016; 61 (4): 467-473

    Abstract

    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 [6] 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 Morris, T., Meredith, O., Schulman, M., Morton, C. H. 2016; 26 (3): 329-335

    Abstract

    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 Main, E. K., McCain, C. L., Morton, C. H., Holtby, S., Lawton, E. S. 2015; 125 (4): 938-947

    Abstract

    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 Hameed, A. B., Lawton, E. S., McCain, C. L., Morton, C. H., Mitchell, C., Main, E. K., Foster, E. 2015

    Abstract

    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 Morton, C. H. 2014; 41 (2): 119-121

    View details for DOI 10.1111/birt.12117

    View details for Web of Science ID 000337298500001

    View details for PubMedID 24851998

  • California Pregnancy-Associated Mortality Review: Mixed methods approach for improved case identification, cause of death analyses and translation of findings Maternal Child Health Journal Mitchell, C., Elizabeth Lawton MHS, Christine Morton PhD, Christy McCain MPH, Sue Holtby MPH, Elliott Main MD 2013
  • Creating a Public Agenda for Maternity Safety and Quality in Cesarean Delivery OBSTETRICS AND GYNECOLOGY Main, E. K., Morton, C. H., Melsop, K., Hopkins, D., Giuliani, G., Gould, J. B. 2012; 120 (5): 1194-1198

    Abstract

    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 Reiger, K., Christine Morton 2012; 2 (3): 173-186
  • Safety in childbirth and the three ‘C’s: community, context, and culture Midwifery Sandall, J., Christine Morton, Debra Bick 2010; 26: 481-482