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Paradoxical Trends and Racial Differences in Obstetric Quality and Neonatal and Maternal Mortality

Howell, Elizabeth A. MD, MPP; Zeitlin, Jennifer DSc, MA; Hebert, Paul PhD; Balbierz, Amy MPH; Egorova, Natalia PhD, MPH

doi: 10.1097/AOG.0b013e3182932238
Original Research

OBJECTIVE: To evaluate trends by race in Agency for Healthcare Research and Quality obstetric-related quality and safety indicators and their relationships to trends in inpatient maternal and neonatal mortality.

METHODS: We used the Nationwide Inpatient Sample from 2000 through 2009 and calculated obstetric hospital quality and patient safety indicators and inpatient maternal and neonatal mortality stratified by race. We examined differences in age and comorbidity-adjusted trends in black compared with white women over time in the United States and by geographic region. Proportions were analyzed by χ2 and trends by regression analysis.

RESULTS: Obstetric quality indicators varied by geographic region, but changes over time were consistent for both races. Cesarean deliveries increased similarly for black and white women, and vaginal births after cesarean delivery declined for both races but more rapidly for white women than for black women. Obstetric safety indicators improved over the study period for black and white women, with obstetric trauma decreasing significantly for both groups (28% compared with 35%, respectively) and birth trauma–injury to neonates declining for both, but changes were not significant. In striking contrast, inpatient maternal and neonatal mortality remained relatively constant during the study period, with persistently higher rates of both seen among black compared with white women (12.0 compared with 4.6 per 100,000 deliveries, P<.001 and 6.6 compared with 2.5 per 1,000 births, P<.001, respectively, in 2009).

CONCLUSION: Improvements in Agency for Healthcare Research and Quality quality indicators for obstetrics are not reflected in improvements in maternal and neonatal morbidity and mortality and do not explain continued racial disparities for outcomes in pregnancies in black and white women. Quality measures that are related to pregnancy outcomes are needed and these should elucidate obstetric health disparities.


Despite improvements in some parameters of obstetric quality and safety for both black and white women from 2000 to 2009, racial disparities in maternal and neonatal mortality persist.

Departments of Health Evidence & Policy, Obstetrics, Gynecology, and Reproductive Science, and Psychiatry, Mount Sinai School of Medicine, New York, New York; the Epidemiological Research Unit on Perinatal Health and Women's and Children's Health, UMRS 953, INSERM Paris, France; and the Department of Health Services, University of Washington School of Public Health, Seattle, Washington.

Corresponding author: Elizabeth A. Howell, MD, MPP, Department of Health Evidence & Policy, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1077, New York, NY 10029-6574; e-mail:

Supported by grant number R21HD068765 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Eunice Kennedy Shriver National Institute of Child Health and Human Development or the National Institutes of Health. Dr. Zeitlin received funding from the European Commission, Research Directorate, Marie Curie, IOF Fellowship, grant number 254171.

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented at Academy Health Annual Research Meeting, June 27–28, 2010, Boston, Massachusetts.

© 2013 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.