HEALTH DISPARITY IN PERINATAL/NEONATAL SETTINGS: WHAT CAN NEONATAL NURSES DO?
Black women and white women have similar incidences of breast cancer. However, mortality is 40% higher among Black women for various reasons, including that more Black women present at an advanced stage of the disease. Furthermore, health disparities do exist in perinatal settings across race, ethnicity, geographical locations, language, and varying socioeconomic factors, and some are unique to these populations.3 This short article briefly reviews available data important to the neonatal nurses and discusses the Vermont Oxford Network recommendations related to “Health Equity: Potentially Better Practices” published in August 2020.4
Neonatal nurses are experts in understanding the impact of maternal health on the health of neonates. Numerous pregnancy-related complications threaten the infants who traverse the neonatal intensive care unit (NICU), such as gestational diabetes (GDM), preeclampsia, or even pregnancy-related death. Pregnancy-related deaths in the United States from 2007 to 2016 were 16.7 per 100,000 live births. The pregnancy-related death rate (per 100,000 live births) was higher for Black (n = 41) and American Indian/Alaskan Native women (n = 30) than for white women (n = 13).5 The proportion of race-specific disparity remained throughout the analyzed period (did not change over time, although we know that caregiving practices did improve during this time period). The Black to white disparity ratio was the highest for age 30- to 34-year-old category, with Black women 4 times more likely than white women to die from pregnancy-related complications. Education also had an impact. Women with less than high school education had twice the pregnancy-related mortality rate than college-educated women (21.6 vs 10.9, respectively); as you might guess, Black women were more represented in that group.5
Pregnancy-induced hypertension (PIH) is well known to neonatal nurses. PIH presents more than twice the stroke risk for Black and Hispanic women than for white women (Blacks: aRR= 2.07; 95% CI, 1.86-2.3; Hispanics: aRR = 2.19; 95% CI, 1.98-2.43). Further, considering all women with chronic hypertension, minority women experience a higher stroke risk (Blacks: aRR = 1.71; 95% CI, 1.30-2.26; Hispanics: aRR = 1.75; 95% CI, 2.32-5.63; Asian/Pacific Islanders: aRR = 3.62; 95% CI, 2.32-5.63). Even more striking is that Black women experience a higher stroke-risk even with no previous chronic hypertension before developing PIH.6
GDM is also a common subject in NICUs. Infants of diabetic mothers, even with well-controlled GDM, are at risk for a wide range of potential complications. Some women develop type 2 DM post-GDM experience. Black women are at a 63% higher risk (95% CI, 1.11-2.39; P = .01) than white women of developing type 2 DM after experiencing GDM.7 For Hispanic women, this risk is twice as high as that of the white women (hazard ratio = 2.22; 95% CI, 1.47-3.35; P < .001). The impact on neonatal morbidities is highly concerning.
Infant mortality rates reveal significant disparities. The Black infant mortality rate in 2017 for the US was more than twice that of white infants (10.9 vs 4.7 per 1000 live births).8 Preterm birth is one of the main contributing factors to infant mortality. The overall US preterm birth rate (<37-week) in 2017 was 9.9%. Black preterm birth rate (13.9%) was significantly higher than white or Hispanic preterm birth rates (9.1% or 9.6%, respectively).9 Although preterm birth rate saw a decline from 2007 (10.44%) to 2014 (9.57%), an increase was seen in 2015 (9.63%). This increase was primarily due to a rise in preterm birth of Black and Hispanic infants.10 During the same period, rates of preterm birth less than 34 weeks remained relatively unchanged (2.93% in 2007, 2.81% in 2011, and 2.76% in 2015). The rate of preterm birth less than 34 weeks in 2015, however, was higher among the Black infants (3.09%) than among the white infants (1.27%). Recurrent preterm birth is higher among the Black women. Furthermore, Black women are more likely to face recurrent preterm births (aOR = 4.11; 95% CI, 3.78-4.47) and premature rupture of membrane (aOR = 6.4; 95% CI, 3.7-11) than white women.11
Recent findings related to racial/ethnic disparities for outcomes of extremely preterm infants born from 2002 to 201612 reported a decrease in hospital mortality rates across all groups, and rates of improvement over time were also similar (Black infants went from 35% to 24%, Hispanic from 32% to 27%, and white from 30% to 22%). However, rates of late-onset sepsis initially were higher for Black and Hispanic infants than for white infants (37%, 45%, and 36%, respectively); however, the prominent decrease narrowed the gap in the final years, with Black and Hispanic rates lower than those of the white infants (24%, 23%, and 25%, respectively). Composite outcomes of late-onset sepsis or death went from 59% to 40% for Black infants, 62% to 42% for Hispanic infants, and 54% to 40% for white infants over time, again, narrowing the gap.
While the progress in care of the extreme preterm population is encouraging, perinatal/neonatal communities have begun only recently to address the disparity topic more robustly. In the position statement on racial disparity in the NICU, “NANN endorses healthcare equality for all infants regardless of race, parental economic or educational status or geographic areas.”13 Yet, bringing equality requires focused and purposeful efforts to understand the social determinants of health in addition to only race and ethnicity differences, such as “language” and communication abilities (health literacy com-pounded by those whose primary language is not English) of our families.14 This can be an uncomfortable topic to some, and it is even more uncomfortable to look in the mirror to examine our unconscious realm.
The Vermont Oxford Network15 has invested in this topic at the annual quality congress in the recent years to raise awareness and to allow the voice of the minority patients and families to be heard. The newest publication by Horbar et al16 proposes that we must practice “social as well as technical medicine and follow through,” suggesting a more comprehensive set of efforts than currently accepted follow-up practices in order to support the NICU families when they take home high-risk infants. Potentially Better Practices for Follow Through is freely available online and includes recommendations to4:
- Promote a culture of equity;
- Identify social risks of families and provide interventions to prevent and mitigate those risks;
- Take action to assist families after discharge (transition to home);
- Maintain support for families through infancy;
- Develop robust quality improvement efforts to ensure equitable, high-quality NICU and follow-through care to all newborns by eliminating modifiable disparities; and
- Advocate for social justice at the local, state, and national levels.
Neonatal nurses are collectively the strongest advocate for the NICU infants and their families; thus, being equipped with the knowledge of better practices to address disparity issues can make a difference today and in the future. Neonatal nurses need to consider how their own unconscious biases can potentially and subconsciously affect practices in more of a covert way. One may say that “I am not biased and no bias ever impacted my practice or attitude toward any families.” Next time, you meet a family who does not speak English, or a family who has vastly different practice norms than what you are used to, would you be able to step back a bit to reflect and reset your perspectives?
Only when neonatal nurses can work toward establishing policies and standards that address these sensitive interactions or encounters that are critical to best practices with infants and families can we begin to promote a true culture of equity. We all need to be more self-aware and more considerate to those who may not come from your own culture, those of a different race, ethnicity, or social class.
1. Breast cancer rates among Black women and White women. https://www.cdc.gov/cancer/dcpc/research/articles/breast_cancer_rates_women.htm
. Published 2018. Accessed August 26, 2020.
2. Richardson LC, Henley SJ, Miller JW, Massetti G, Thomas CC. Patterns and trends in age-specific Black–White differences in breast cancer incidence and mortality—United States, 1999-2014. MMWR Morb Mortal Wkly Rep. 2016;65(40):1093–1098.
3. Sigurdson K, Mitchell B, Liu J, et al. Racial/ethnic disparities in neonatal intensive care: a systematic review. Pediatrics. 2019;144(2):e20183114.
4. Vermont Oxford Network for Health Equity: potentially better practices for follow through. https://public.vtoxford.org/health-equity/potentially-better-practices-for-follow-through
. Published 2018. Accessed September 2, 2020.
5. Racial/ethnic disparities in pregnancy-related death—United States, 2007-2016. https://www.cdc.gov/mmwr/volumes/68/wr/mm6835a3.htm
. Published 2019. Accessed September 1, 2020.
6. Miller EC, Zambrano Espinoza MD, Huang Y, et al. Maternal race/ethnicity, hypertension, and risk for stroke during delivery admission. J Am Heart Assoc. 2020;9(3):e014775.
7. Bower JK, Butler BN, Bose-Brill S, Kue J, Wassel CL. Racial/ethnic differences in diabetes screening and hyperglycemia among US women after gestational diabetes. Prev Chronic Dis. 2019;16:E145.
10. Manuck TA. Racial and ethnic differences in preterm birth: a complex, multifactorial problem. Semin Perinatol. 2017;41(8):511–518.
11. 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(4):373.e1–e7.
12. Travers CP, Carlo WA, McDonald SA, et al. Racial/ethnic disparities among extremely preterm infants in the United States from 2002 to 2016. JAMA Netw Open. 2020;3(6):e206757.
13. NANN Board of Directors. Racial Disparity in the NICU. Position Statement, #3070. Chicago, IL: National Association of Neonatal Nurses; 2020.
14. Sigurdson K, Morton C, Mitchell B, Profit J. Disparities in NICU quality of care: a qualitative study of family and clinician accounts. J Perinatol. 2018;38(5):600–607.
15. Vermont Oxford Network. Home page. https://public.vtoxford.org
. Published 2020. Accessed September 2, 2020.
16. Horbar JD, Edwards EM, Ogbulu Y. Our responsibility to follow through for NICU infants and their families. Pediatrics. 2020:e20200360. doi:10.1542/peds.2020-0360.