Patient Race and Racial Composition of Delivery Unit Associated With Disparities in Severe Maternal Morbidity: A Multistate Analysis 2007–2014 : Obstetric Anesthesia Digest

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Patient Race and Racial Composition of Delivery Unit Associated With Disparities in Severe Maternal Morbidity: A Multistate Analysis 2007–2014

Sastow, D.L.; Jiang, S.Y.; Tangel, V.E.; Matthews, K.C.; Abramovitz, S.E.; Oxford-Horrey, C.M.; White, R.S.

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doi: 10.1097/01.aoa.0000852964.41650.d0
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Abstract

Black women have a higher rate of severe maternal morbidity (SMM) than non-Hispanic White women. Although investigations of SMM and race/ethnicity have typically centered around inequalities at the patient level, SMM is also associated with quality of care at the hospital level. Mothers who give birth in hospitals that serve a disproportionate number of black women (Black-serving hospitals) are more likely to have SMM than mothers who deliver at hospitals that serve fewer black women. Likewise, mothers who deliver at hospitals with a relatively greater proportion of patients without insurance or on public insurance (safety-net burden) have an increased risk for SMM. Few studies have investigated the relationship between hospital-level and patient‐level factors and risk for SMM. Using State Inpatient Databases (SID), data from Healthcare and Cost and Utilization Project (HCUP), and Agency for Healthcare Research and Quality (AHRQ) for the years 2007–2014, this retrospective observational study attempted to calculate the odds of SMM with the hospital-level factors of safety-net burden and Black-serving classification, both separately and in conjunction with the patient’s race/ethnicity.

The analysis was compiled from 6879,332 delivery hospitalizations from New York, Kentucky, Maryland, California, and Florida. Percentiles at the hospital level were calculated based on the hospitals’ rankings as Black-serving delivery units and comparative safety-net burden. Other variables included the location (state) and the hospital’s total delivery volume. The key patient‐level variable was race/ethnicity. Other patient‐level variables included parturient age, insurance classification, median income (based on the patient’s ZIP code), type of delivery, and obstetric‐related comorbidities.

The results underlined the relationship between hospital-level factors and a patient’s race/ethnicity on the probability of SMM. Following adjustment for patient‐level factors, women who delivered in Black‐serving delivery units were found to have higher incidence of SMM. Furthermore, the negative outcomes from delivering in hospitals characterized as Black‐serving were more pronounced for Black compared with White patients.

Although patient outcomes in previous studies have been shown to be impacted by a greater hospital safety‐net burden, the results from this analysis indicate that having no insurance or public insurance are not in themselves factors associated with SMM. However, interaction assessments indicate that Black patients at hospitals with a greater safety‐net burden delivery have elevated chances of SMM, thus emphasizing the potential impact of structural racism on maternal health outcomes.

Limitations to the study include imprecise and inadequate documentation, the misidentification of comorbidities, and general lack of substantiated clinical information. Additional limitations are the possible impact of unmeasured confounders since the records do not allow for confounders such as medications and disease severity.

The research underscores the need of a multilayered approach to address disparities in maternal care, including cultural, clinical, and fiscal interventions for delivery units that disproportionately serve Black patients.

Keywords:

Maternal Morbidity and Mortality

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