Changes in inpatient quality indicators were evident over the study period with primary cesarean delivery rates increasing and vaginal births after cesarean delivery decreasing. Cesarean delivery rates for white women increased from 197.5 per 1,000 deliveries in 2000 to 303.0 per 1,000 deliveries in 2009, an increase of 53%. Likewise, cesarean delivery rates for black women increased from 225.1 per 1,000 deliveries in 2000 to 330.8 per 1,000 deliveries in 2009, an increase of 47%. The rate of change was similar for both groups. Throughout the study period, risk-adjusted cesarean delivery rates were higher for black women than for white women (Fig. 1).
In contrast, the rate of decline for vaginal birth after cesarean delivery was more rapid for white women than black women. Rates of vaginal birth after cesarean delivery decreased by 74% for white women compared with 66% for black women (P<.001), and the decline occurred earlier for white women (Fig. 1). Throughout the study period, risk-adjusted vaginal birth after cesarean delivery rates remained higher among black women than white women.
Quality and patient safety indicators varied by geographic region for white and black women, but trends over time were similar for both groups (Table 2). For example, although primary cesarean delivery rates increased for black and white women over the 10-year period, there was wide variation in rates of cesarean delivery depending on geographic region. Rates in 2009 ranged from a low for white and black women (170.9 and 185.2 per 1,000 births, respectively) in the Midwest to a high (206.9 and 219.7 per 1,000 births, respectively) in the South. Similar to national trends, the decline in vaginal birth after cesarean delivery rates occurred more rapidly for white women than for black women, and this decline appeared to be most pronounced for the Northeast region.
Unlike dramatic changes in patient safety and inpatient quality indicators during the study period, inpatient maternal and neonatal mortality did not change substantially between 2000 and 2009 (Fig. 2) with persistently higher rates of both seen in black women 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).
Sensitivity analyses were conducted to compare rates of inpatient quality indicators and patient safety indicators for all hospitals compared with those hospitals with race for at least 80% of deliveries. Rates and trends in the overall sample were very similar to those in the group of hospitals with race data (Table 3). We also conducted sensitivity analyses for delivery volume and compared rates of inpatient quality indicators and patient safety indicators for all hospitals and those hospitals with at least 10 deliveries and found no significant difference in reporting between these two groups.
This article provides a nationally representative overview of obstetric quality for black and white women as measured using the Agency for Healthcare Research and Quality quality indicators. Our analyses demonstrate that some parameters of obstetric-related quality improved from 2000 to 2009. We found that patient safety indicators, in particular obstetric trauma during delivery, decreased markedly overall and for black and white women during this period. At the same time, inpatient quality indicators also changed for women. Cesarean delivery rates rose, whereas vaginal birth after cesarean delivery rates decreased during this period and these changes are consistent with published literature of this period and with changes in American College of Obstetricians and Gynecologists guidelines on safety of vaginal birth after cesarean delivery.20–22 However, our findings suggest a paradox: despite improvements in some parameters of hospital quality, inpatient maternal and neonatal mortality remained relatively stable.
During this period of increased attention to hospital quality, parameters of hospital quality and patient safety in obstetrics had similar patterns for black and white women. However, one exception was the rate of decline in vaginal birth after cesarean delivery rates, which was higher for white women than for black women and raises the hypothesis that the rate of uptake of practice-based guidelines may vary for patients by race. Whether this finding is the result of hospital site of care, patient decision-making, or health care provider decision-making cannot be determined with the use of this data set. Our findings that black women had lower rates of obstetric trauma and higher rates of cesarean deliveries than white women and that cesarean delivery rates vary by region are consistent with previous literature.23–26
Our findings suggest that the seven Agency for Healthcare Research and Quality obstetric quality and safety indicators are not associated with maternal and neonatal mortality. The Agency for Healthcare Research and Quality indicators were extensively tested for feasibility, validated according to strict criteria, and do assess domains within the Institute of Medicine's suggested six domains of quality (safety, effectiveness, patient-centered, timeliness, efficiency, and equity).15,27 However, they may not be associated with the underlying factors that are most important for explaining variation between hospitals in maternal and neonatal mortality.
Quality measures focused on more crucial processes of care on the pathway to maternal and neonatal mortality (such as the use of antenatal steroids in the setting of preterm delivery or the use of hemorrhage protocols in the delivery suite) are needed and may be targets for quality improvement activities.13,28,29 The Joint Commission recently endorsed the use of antenatal steroids as a perinatal quality measure.30 Others have endorsed quality measures such as elective delivery before 39 weeks of gestation, health care-associated bloodstream infections in newborns, deep venous thrombosis prophylaxis, and antibiotics in different settings including preterm premature rupture of membranes.31–34
Our findings also suggest that quality measures sensitive to disparities, or measures that are helpful in reducing disparities, are needed in obstetrics. The National Quality Forum has endorsed disparities-sensitive quality measures in other areas of medicine.35 One such potential obstetric measure is the use of antibiotics in the setting of preterm premature rupture of membranes. Given the high prevalence of preterm premature rupture of membranes among black mothers,36 its strong association with neonatal morbidity and mortality,37 and the evidence base for use of antibiotics in this setting,33 this measure may have the potential to help hospitals narrow disparities.
There are limitations with our study. Maternal mortality is underreported and rates of inpatient maternal mortality from the Nationwide Inpatient Sample are lower than reports enhanced by case ascertainment.38,39 Race data in the Nationwide Inpatient Sample are incomplete because of differences in state and hospital procedures for collecting race data and this could create bias if hospitals with missing race had different rates for these indicators or if differentials between white and black women did not follow the patterns observed in other hospitals.19 However, sensitivity analyses demonstrated no differences between hospitals that coded race and those that did not code race in terms of quality and safety indicators. We were also not able to sufficiently control for socioeconomic and environmental factors that likely contribute to disparities in outcomes with the use of administrative data. There are limitations inherent to use of ICD-9-CM codes to conduct medical research. Nevertheless, one of the strengths of Agency for Healthcare Research and Quality quality indicators is that they are ascertainable from routine administrative data.
Our study examined national trends in obstetric quality and safety and neonatal and maternal mortality stratified for black and white patients. We found that trends in Agency for Healthcare Research and Quality obstetric quality indicators and maternal and neonatal mortality were not aligned. Despite improvements in some parameters of obstetric quality, neonatal and maternal mortality rates stagnated and these indicators are unable to inform care focused on narrowing disparities. Given that minority women account for 50% of births and persistent racial disparities in maternal and neonatal mortality persist, quality measures that address disparities are very much needed. Future research should document what modifications to existing measures or which new measures might help elucidate disparities that exist as well as the improvement initiatives that could be used to reduce morbidity and mortality and the intractable racial disparities in perinatal outcomes.
1. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Kirmeyer S. Births: final data for 2004. Natl Vital Stat Rep 2006;55:1–101.
2. Andrews RM. The national hospital bill: the most expensive conditions by payer, 2008. In: HCUP Statistical Brief 59. Rockville (MD): Agency for Healthcare, Research, and Quality; 2008.
3. Asch DA, Nicholson S, Srinivas S, Herrin J, Epstein AJ. Evaluating obstetrical residency programs using patient outcomes. JAMA 2009;302:1277–83.
4. Gregory KD, Fridman M, Shah S, Korst LM. Global measures of quality- and patient safety-related childbirth outcomes: should we monitor adverse or ideal rates? Am J Obstet Gynecol 2009;200:681.e1–7.
5. Srinivas SK, Epstein AJ, Nicholson S, Herrin J, Asch DA. Improvements in US maternal obstetrical outcomes from 1992 to 2006. Med Care 2010;48:487–93.
6. Guendelman S, Thornton D, Gould J, Hosang N. Obstetric complications during labor and delivery: assessing ethnic differences in California. Womens Health Issues 2006;16:189–97.
7. Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality in the United States, 1998 to 2005. Obstet Gynecol 2010;116:1302–9.
8. U.S. Department of Health and Human Services. Healthy People 2010. In: Understanding and improving health. 2nd ed. Washington, DC: U.S. Government Printing Office; 2000.
9. Howell EA, Hebert P, Chatterjee S, Kleinman LC, Chassin MR. Black/white differences in very low birth weight neonatal mortality rates among New York City hospitals. Pediatrics 2008;121:e407–15.
10. Clark SL, Frye DR, Meyers JA, Belfort MA, Dildy GA, Kofford S, et al.. Reduction in elective delivery at <39 weeks of gestation: comparative effectiveness of 3 approaches to change and the impact on neonatal intensive care admission and stillbirth. Am J Obstet Gynecol 2010;203:449.e1–6.
11. Morales LS, Staiger D, Horbar JD, Carpenter J, Kenny M, Geppert J, et al.. Mortality among very low-birthweight infants in hospitals serving minority populations. Am J Public Health 2005;95:2206–12.
12. Geller SE, Cox SM, Callaghan WM, Berg CJ. Morbidity and mortality in pregnancy: laying the groundwork for safe motherhood. Womens Health Issues 2006;16:176–88.
13. Skupski DW, Lowenwirt IP, Weinbaum FI, Brodsky D, Danek M, Eglinton GS. Improving hospital systems for the care of women with major obstetric hemorrhage. Obstet Gynecol 2006;107:977–83.
14. Berg CJ, Harper MA, Atkinson SM, Bell EA, Brown HL, Hage ML, et al.. Preventability of pregnancy-related deaths: results of a state-wide review. Obstet Gynecol 2005;106:1228–34.
18. Phibbs CS, Baker LC, Caughey AB, Danielsen B, Schmitt SK, Phibbs RH. Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants. N Engl J Med 2007;356:2165–75.
20. Rose VL. ACOG urges a cautious approach to vaginal birth after cesarean delivery. Am Fam Physician 1999;60:1245–6.
21. Coleman VH, Erickson K, Schulkin J, Zinberg S, Sachs BP. Vaginal birth after cesarean delivery: practice patterns of obstetrician-gynecologists. J Reprod Med 2005;50:261–6.
22. Declercq E, Young R, Cabral H, Ecker J. Is a rising cesarean delivery rate inevitable? Trends in industrialized countries, 1987 to 2007. Birth 2011;38:99–104.
23. Goldberg J, Hyslop T, Tolosa JE, Sultana C. Racial differences in severe perineal lacerations after vaginal delivery. Am J Obstet Gynecol 2003;188:1063–7.
24. Getahun D, Strickland D, Lawrence JM, Fassett MJ, Koebnick C, Jacobsen SJ. Racial and ethnic disparities in the trends in primary cesarean delivery based on indications. Am J Obstet Gynecol 2009;201:422.e1–7.
25. Bryant AS, Washington S, Kuppermann M, Cheng YW, Caughey AB. Quality and equality in obstetric care: racial and ethnic differences in caesarean section delivery rates. Paediatr Perinat Epidemiol 2009;23:454–62.
26. Baicker K, Buckles KS, Chandra A. Geographic variation in the appropriate use of cesarean delivery. Health Aff (Millwood) 2006;25:w355–67.
27. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC; Institute of Medicine; 2001.
28. Howell EA, Stone J, Kleinman LC, Inamdar S, Matseoane S, Chassin MR. Approaching NIH guideline recommended care for maternal-infant health: clinical failures to use recommended antenatal corticosteroids. Matern Child Health J 2010;14:430–6.
29. Lee HC, Lyndon A, Blumenfeld YJ, Dudley RA, Gould JB. Antenatal steroid administration for premature neonates in California. Obstet Gynecol 2011;117:603–9.
31. Main EK. New perinatal quality measures from the National Quality Forum, the Joint Commission and the Leapfrog Group. Curr Opin Obstet Gynecol 2009;21:532–40.
32. Korst LM, Gregory KD, Lu MC, Reyes C, Hobel CJ, Chavez GF. A Framework for the Development of maternal quality of care indicators. Matern Child Health J 2005;9:317–41.
33. Cousens S, Blencowe H, Gravett M, Lawn JE. Antibiotics for pre-term pre-labour rupture of membranes: prevention of neonatal deaths due to complications of pre-term birth and infection. Int J Epidemiol 2010;39(suppl 1):i134–43.
34. Mann S, Pratt S, Gluck P, Nielsen P, Risser D, Greenberg P, et al.. Assessing quality obstetrical care: development of standardized measures. Jt Comm J Qual Patient Saf 2006;32:497–505.
35. National Quality Forum. Healthcare disparities and cultural competency consensus standards: disparities-sensitive measure assessment. Washingto, DC: National Quality Forum; 2012.
36. Shen TT, DeFranco EA, Stamilio DM, Chang JJ, Muglia LJ. A population-based study of race-specific risk for preterm premature rupture of membranes. Am J Obstet Gynecol 2008;199:373.e1–7.
37. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet 2008;371:75–84.
38. Lang CT, King JC. Maternal mortality in the United States. Best Pract Res Clin Obstet Gynaecol 2008;22:517–31.
39. Deneux-Tharaux C, Berg C, Bouvier-Colle MH, Gissler M, Harper M, Nannini A, et al.. Underreporting of pregnancy-related mortality in the United States and Europe. Obstet Gynecol 2005;106:684–92.