Site of delivery contribution to black-white severe maternal morbidity disparity.

The black-white maternal mortality disparity is the largest disparity among all conventional population perinatal health measures, and the mortality gap between black and white women in New York City has nearly doubled in recent years. For every maternal death, 100 women experience severe maternal morbidity, a life-threatening diagnosis, or undergo a life-saving procedure during their delivery hospitalization. Like maternal mortality, severe maternal morbidity is more common among black than white women. A significant portion of maternal morbidity and mortality is preventable, making quality of care in hospitals a critical lever for improving outcomes. Hospital variation in risk-adjusted severe maternal morbidity rates exists. The extent to which variation in hospital performance on severe maternal morbidity rates contributes to black-white disparities in New York City hospitals has not been studied. We examined the extent to which black-white differences in severe maternal morbidity rates in New York City hospitals can be explained by differences in the hospitals in which black and white women deliver. We conducted a population-based study using linked 2011-2013 New York City discharge and birth certificate datasets (n = 353,773 deliveries) to examine black-white differences in severe maternal morbidity rates in New York City hospitals. A mixed-effects logistic regression with a random hospital-specific intercept was used to generate risk-standardized severe maternal morbidity rates for each hospital (n = 40). We then assessed differences in the distributions of black and white deliveries among these hospitals. Severe maternal morbidity occurred in 8882 deliveries (2.5%) and was higher among black than white women (4.2% vs 1.5%, P < .001). After adjustment for patient characteristics and comorbidities, the risk remained elevated for black women (odds ratio, 2.02; 95% confidence interval, 1.89-2.17). Risk-standardized severe maternal morbidity rates among New York City hospitals ranged from 0.8 to 5.7 per 100 deliveries. White deliveries were more likely to be delivered in low-morbidity hospitals: 65% of white vs 23% of black deliveries occurred in hospitals in the lowest tertile for morbidity. We estimated that black-white differences in delivery location may contribute as much as 47.7% of the racial disparity in severe maternal morbidity rates in New York City. Black mothers are more likely to deliver at higher risk-standardized severe maternal morbidity hospitals than are white mothers, contributing to black-white disparities. More research is needed to understand the attributes of high-performing hospitals and to share best practices among hospitals.

Howell EA ，Egorova NN ，Balbierz A ，Zeitlin J ，Hebert PL ... -  《-》

Severe Maternal Morbidity Among Hispanic Women in New York City: Investigation of Health Disparities.

Howell EA ，Egorova NN ，Janevic T ，Balbierz A ，Zeitlin J ，Hebert PL ... -  《-》

Differences in Morbidity and Mortality Rates in Black, White, and Hispanic Very Preterm Infants Among New York City Hospitals.

Howell EA ，Janevic T ，Hebert PL ，Egorova NN ，Balbierz A ，Zeitlin J ... -  《-》

Black-white differences in severe maternal morbidity and site of care.

For every maternal death, >100 women experience severe maternal morbidity, which is a life-threatening diagnosis, or undergo a life-saving procedure during their delivery hospitalization. Similar to racial/ethnic disparities in maternal death, black women are more likely to experience severe maternal morbidity than white women. Site of care has received attention as a mechanism to explain disparities in other areas of medicine. Data indicate that black women receive care in a concentrated set of hospitals and that these hospitals appear to provide lower quality of care. Whether racial differences in the site of delivery contribute to observed black-white disparities in severe maternal morbidity rates is unknown. The purpose of this study was to determine whether hospitals with high proportions of black deliveries have higher severe maternal morbidity and whether such differences contribute to overall black-white disparities in severe maternal morbidity. We used a published algorithm to identify cases of severe maternal morbidity during deliveries in the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project for 2010 and 2011. We ranked hospitals by their proportion of black deliveries into high black-serving (top 5%), medium black-serving (5% to 25% range), and low black-serving hospitals. We analyzed the risks of severe maternal morbidity for black and white women by hospital black-serving status using logistic regressions that were adjusted for patient characteristics, comorbidities, hospital characteristics, and within-hospital clustering. We then derived adjusted rates from these models. Seventy-four percent of black deliveries occurred at high and medium black-serving hospitals. Overall, severe maternal morbidity occurred more frequently among black than white women (25.8 vs 11.8 per 1000 deliveries, respectively; P < .001); after adjustment for the distribution of patient characteristics and comorbidities, this differential declined but remained elevated (18.8 vs 13.3 per 1000 deliveries, respectively; P < .001). Women who delivered in high and medium black-serving hospitals had elevated rates of severe maternal morbidity rates compared with those in low black-serving hospitals in unadjusted (29.4 and 19.4 vs 12.2 per 1000 deliveries, respectively; P < .001) and adjusted analyses (17.3 and 16.5 vs 13.5 per 1000 deliveries, respectively; P < .001). Black women who delivered at high black-serving hospitals had the highest risk of poor outcomes. Most black deliveries occur in a concentrated set of hospitals, and these hospitals have higher severe maternal morbidity rates. Targeting quality improvement efforts at these hospitals may improve care for all deliveries and disproportionately impact care for black women.

Howell EA ，Egorova N ，Balbierz A ，Zeitlin J ，Hebert PL ... -  《-》

Black/white differences in very low birth weight neonatal mortality rates among New York City hospitals.

Howell EA ，Hebert P ，Chatterjee S ，Kleinman LC ，Chassin MR ... -  《-》