Blacks and Hispanics have higher preemie morbidity and mortality than whites, and poor performance in the hospital of birth explains 30% to 40% of that disparity, a study found.
Elizabeth Howell, MD, MPP, from Icahn School of Medicine at Mount Sinai, New York City, and colleagues published their findings online January 2 in JAMA Pediatrics.
“The real focus here is to try to reduce morbidity in preterm babies and give these kids a chance at a healthier life. This study shines light on the idea that we really need to focus on narrowing disparities when we think about quality improvement. Additionally, these disparities are not just local to New York City. We know that there are infant and neonatal racial and ethnic disparities that have been longstanding in this country,” Dr Howell said in a news release.
During the last decade, the United States has made strides in improving neonatal care, yet racial and ethnic disparities persist. Some studies have suggested that black newborns die at more than twice the rate of non-Hispanic whites. Research also suggests that black and Hispanic preterm infants are at increased risk for serious birth complications, which can affect the lungs, eyes, intestines, and brain. Such complications can set the stage for health problems throughout life and perpetuate socioeconomic disparities.
To investigate whether quality of care contributes to these disparities, the researchers used data from hospital discharges and birth certificates to analyze morbidity and mortality rates in black, Hispanic, and white very preterm infants. The study included 7177 genetically normal infants born between 24 and 31 weeks of gestation at 39 New York City hospitals between 2010 and 2014. The researchers calculated risk-adjusted neonatal morbidity and mortality rates, then used these results to rank hospitals and evaluate differences for black, Hispanic, and white very preterm infants.
The overall morbidity and mortality rate was 28% (n = 2011). This rate was significantly higher among black (32.2%; n = 893) and Hispanic (28.1%; n = 610) infants than among white infants (22.5%; n = 319) (two-tailed P < .001).
Infants born in hospitals with the highest morbidity and mortality rates had twice the rate of serious complications and death as those born in hospitals with the lowest rates (0.40 [95% confidence interval (CI), 0.38 – 0.41] vs 0.16 [95% CI, 0.14 – 0.18], respectively).
Very preterm black (43.4%, 1204 of 2775) and Hispanic (34.4%; 746 of 2168) infants were more likely than white infants (22.9%; 325 of 1418) to be born in hospitals with the highest morbidity and mortality rates (two-tailed P < .001).
A large proportion of these disparities was attributed to poor performance in the birth hospital. The fact that white mothers received care at better-performing hospitals explained 39.9% of black-white differences and 29.5% of Hispanic-white differences.
The authors mention several limitations to their study. Although the study adjusted for several social factors that could affect infant outcomes, such as health insurance, educational level, prenatal care, smoking, and drug use during pregnancy, it could not adjust for other related factors, such as crime and neighborhood poverty. Also, although the results may apply to similar urban environments, they may not generalize more broadly. Further study is needed to see whether the results apply nationwide.
If they do, it would indicate an “alarming driver” of disparities in neonatal outcomes based on race/ethnicity, Ciaran Phibbs, PhD, from Stanford University School of Medicine, California, and Scott Lorch, MD, MSCE, from the University of Pennsylvania, Philadelphia, write in a linked editorial.
They emphasize moving beyond identifying disparities and figuring out what actually causes them. In particular, the study raises two important questions: Why do a disproportionate number of blacks and Hispanics receive care at the worst-performing hospitals, and why do neonatal outcomes vary so much across hospitals?
“The study from New York City highlights several questions about how women and their doctors choose the hospital where they deliver and what characteristics of these hospitals result in adverse pregnancy outcomes,” they conclude. “These data need to be replicated in other areas to help distinguish unique aspects of the perinatal system in New York City from more global features of how women of minority racial/ethnic status receive care within our perinatal system.”
This study was supported by an award from the National Institutes of Health. The authors and editorialists have disclosed no relevant financial relationships.
JAMA Pediatr. Published online January 2, 2018. Abstract, Editorial
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