Community level factors and racial inequities in delivery hospitalizations involving severe maternal morbidity in the United States, 2016-2019.

The objective of this study was to evaluate the racial and ethnic disparities in delivery hospitalizations involving severe maternal morbidity (SMM) by location of residence and community income. We used the 2016 to 2019 Healthcare Cost and Utilization Project National Inpatient Sample. International Classification of Diseases, Tenth Revision, Clinical Modification codes were used to identify delivery hospitalizations with SMM. Using logistic regression models, we examined the association between race and ethnicity and delivery hospitalizations involving SMM. In adjusted analyses, the models were stratified by location of residence and community income and adjusted for patient and hospital characteristics. In rural areas, non-Hispanic Black women (AOR 1.50; 95% CI 1.25-1.79) and women of other races (AOR 1.32; 95% CI 1.03-1.69) had an increased odds of experiencing a delivery hospitalization involving SMM when compared to non-Hispanic White women. In micropolitan areas, non-Hispanic Black women (AOR 1.88; 95% CI 1.79-1.97), non-Hispanic Asian/Pacific Islander women (AOR 1.54; 95% CI 1.16-2.05), and women of other races (AOR 1.31; 95% CI 1.03-1.67) had an increased odds of experiencing a delivery hospitalization involving SMM when compared to non-Hispanic White women. Non-Hispanic Black women also had increased odds of experiencing a delivery hospitalization involving SMM in communities with the lowest income (quartile 1) (AOR 1.59; 95% CI 1.49-1.66), middle income (quartiles 2 and 3) (AOR 1.81; 95% CI 1.72-1.91), and highest income (AOR 2.09; 95% CI 1.90-2.29) when compared to non-Hispanic White women. We found that location of residence and community income are associated with racial and ethnic differences in SMM in the United States. These factors, outside of individual factors assessed in previous studies, provide a better understanding of some of the structural and systemic factors that may contribute to SMM.

Claridy MD ，Hernandez-Green N ，Rathbun SL ，Cordero JF ... -  《Scientific Reports》

Racial and Ethnic Disparities in Epidural Blood Patch Utilization Among Obstetric Patients in the United States: A Nationwide Analysis, 2016-2020.

Racial and ethnic disparities in health care delivery can lead to inadequate peripartum pain management and associated adverse maternal outcomes. An epidural blood patch (EBP) is the definitive treatment for moderate to severe postdural puncture headache (PDPH), a potentially debilitating neuraxial anesthesia complication associated with significant maternal morbidity if undertreated. In this nationwide study, we examine the racial and ethnic disparities in the inpatient utilization of EBP after obstetric PDPH in the United States. In this retrospective observational study, we used the National Inpatient Sample, a nationally representative database of discharge records for inpatient admissions in the United States, from 2016 to 2020. We analyzed delivery hospitalizations of women of childbearing age (15-49 years) diagnosed with PDPH. Adjusting for maternal and hospitalization characteristics as confounders, we used a multilevel mixed-effects logistic regression model to compare the rates of EBP utilization by race and ethnicity. Secondarily, among hospitalizations with an EBP, we examined the association between race and ethnicity and the timing of the EBP procedure. We analyzed 49,300 delivery hospitalizations with a diagnosis of PDPH. An EBP was performed in 24,075 (48.8%; 95% confidence interval [CI], 47.8%-49.9%) of these hospitalizations. EBP was performed in 52.7% (95% CI, 51.3%-54.1%) of White non-Hispanic patients with PDPH. Compared to White non-Hispanic patients, Black non-Hispanic (adjusted odds ratio [aOR] = 0.69; 99% CI, 0.56-0.84), Hispanic (aOR = 0.80, 99% CI, 0.68-0.95), and Asian or Pacific Islander patients (aOR = 0.74, 99% CI, 0.58-0.96) were less likely to receive an EBP. The median (interquartile range [IQR]) time to perform an EBP was 2 (1-3) days after admission, with 90% of EBP procedures completed within 4 days of admission. There was no significant association between race and ethnicity and the timing of EBP placement. In this nationwide analysis of delivery hospitalizations from 2016 to 2020 in the United States with a diagnosis of PDPH, we identified racial and ethnic disparities in the utilization of EBP. Minoritized patients identified as Black non-Hispanic, Hispanic, or Asian or Pacific Islander were less likely to receive an EBP for the treatment of PDPH compared to White non-Hispanic patients. Suboptimal treatment of PDPH may be associated with adverse long-term outcomes such as postpartum depression, posttraumatic stress disorder, and chronic headaches. Racial and ethnic disparities in EBP utilization should be further investigated to ensure equitable health care delivery.

Potnuru PP ，Jonna S ，Orlando B ，Nwokolo OO ... -  《-》

Delivery-Related Maternal Morbidity and Mortality Among Patients With Cardiac Disease.

To assess the risk of severe maternal morbidity (SMM) and mortality among pregnant patients with cardiovascular disease (CVD). This was a retrospective cohort study of U.S. delivery hospitalizations from 2010 to 2020 using weighted population estimates from the National Inpatient Sample database. The primary objective was to evaluate the risk of SMM and maternal mortality among patients with CVD at delivery hospitalization. International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification codes were used to identify delivery hospitalizations, CVD, and SMM events. Multivariable logistic regression analyses were performed to compare SMM and mortality risk among patients with CVD and those without CVD. Given the substantial racial and ethnic disparities in SMM, mortality, and CVD burden, secondary objectives included evaluating SMM and mortality across racial and ethnic groups and assessing the population attributable fraction within each group. Lastly, subgroup analyses of SMM by underlying CVD diagnoses (eg, congenital heart disease, chronic heart failure) were performed. Variables used in the regression models included socioeconomic and demographic maternal characteristics, maternal comorbidities, and pregnancy-specific complications. Among 38,374,326 individuals with delivery hospitalizations, 203,448 (0.5%) had CVD. Patients with CVD had an increased risk of SMM (11.6 vs 0.7%, adjusted odds ratio [aOR] 12.5, 95% CI, 12.0-13.1) and maternal death (538 vs 5 per 100,000 delivery hospitalizations, aOR 44.1, 95% CI, 35.4-55.0) compared with those without CVD. Patients with chronic heart failure had the highest SMM risk (aOR 354.4, 95% CI, 301.0-417.3) among CVD categories. Black patients with CVD had a higher risk of SMM (aOR 15.9, 95% CI, 14.7-17.1) than those without CVD with an adjusted population attributable fraction of 10.5% (95% CI, 10.0-11.0%). CVD in pregnancy is associated with increased risk of SMM and mortality, with the highest risk of SMM among patients with chronic heart failure. Although CVD affects less than 1% of the pregnant population, it contributes to nearly 1 in 10 SMM events in the United States.

Toledo I ，Czarny H ，DeFranco E ，Warshak C ，Rossi R ... -  《-》

Racial and Ethnic Disparities in Child Abuse Identification and Inpatient Treatment.

Salimi-Jazi F ，Liang NE ，Huang Z ，Tennakoon L ，Rafeeqi T ，Trickey A ，Chao SD ... -  《JAMA Network Open》

Trends in severe maternal morbidity following an institutional team goal strategy for disparity reduction.

Racial disparities in maternal pregnancy outcomes, specifically in morbidity and mortality, are persistent in the U.S., and a multifaceted approach to mitigating these disparate outcomes is critical. In 2020, our health system committed to reducing severe maternal morbidity (SMM) in Black patients, employing multiple strategic interventions including implicit bias training, regular reporting of a composite SMM metric stratified by race and ethnicity, standardization of best practices, focused efforts for hemorrhage risk reduction, and system-wide team building. The goal of this study is to investigate trends in SMM by race across this period of concentrated interventions to improve maternal outcomes overall, and specifically for Black patients. This is a retrospective cohort study evaluating all delivery admissions at an academic, urban, tertiary-care hospital in Philadelphia-one site of a health system encompassing five delivery hospitals-over a 3-year period from 2019 to 2021. Data including patient demographics, clinical features, and outcomes were extracted from the electronic medical record (EMR). Self-reported race was categorized as Black vs non-Black as documented in the EMR. SMM was defined according to established CDC indicators as well as additional codes identified by Vizient for common sources of SMM including hemorrhage, infection, and embolism. Data were analyzed by year with a multivariable logistic regression model including insurance type and obstetric comorbidity index (OB-CMI), a weighted scoring system accounting for numerous chronic medical conditions and antepartum pregnancy complications. In total, 12,339 deliveries were included, 64.6% (N=8012) of which were to Black patients. Median OB-CMI score was higher for Black patients at 3 (interquartile range [IQR] 1-5) compared to 2 (IQR 1-4) for non-Black patients, P<.01. There was a significant decrease in SMM for the entire cohort over the study period (8.5% in 2019 to 6.5% in 2021, P=.001), driven by a decreased rate specifically among Black patients (8.9% in 2019 to 6.6% in 2021, P=.005) with a nonsignificant decrease for non-Black patients (7.8% in 2019 to 6.3% in 2021, P=.21). The adjusted model similarly demonstrated decreased risk of SMM over time for Black patients (2020 vs 2019 adjusted odds ratio [aOR] = 0.81, 95% confidence interval [CI] 0.69-0.96; 2021 vs 2019 aOR 0.73, 95% CI 0.62-0.86). Dedicated efforts to improve equity in maternal outcomes over a 2-year period (2020-2021) in this hospital serving a Black patient majority were associated with a significant decline in SMM, especially among Black patients. This finding demonstrates the success of a high-level, coordinated, and systematic approach in reducing SMM and associated disparities, and is highly consequential in light of the ongoing major epidemic of racial disparities in obstetric outcomes.

Kern-Goldberger AR ，Hirshberg A ，James A ，Levine LD ，Howell E ，Harbuck E ，Srinivas SK ... -  《-》