Racial and Ethnic Disparities in Maternal Outcomes and the Disadvantage of Peripartum Black Women: A Multistate Analysis, 2007–2014

 

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Abstract

Objective Racial and ethnic disparities in obstetric care and delivery outcomes have shown that black women experience high rates of pregnancy-related mortality and morbidity, along with high rates of cesarean delivery, compared with other racial and ethnic groups. We aimed to quantify these disparities and test the effects of race/ethnicity in stratified statistical models by insurance payer and socioeconomic status, adjusting for comorbidities specific to an obstetric population.

Study Design We analyzed maternal outcomes in a sample of 6,872,588 delivery records from California, Florida, Kentucky, Maryland, and New York from 2007 to 2014 from the State Inpatient Databases, Healthcare Cost and Utilization Project. We compared present-on-admission characteristics of parturients by race/ethnicity, and estimated logistic regression and generalized linear models to assess outcomes of in-hospital mortality, cesarean delivery, and length of stay.

Results Compared with white women, black women were more likely to die in-hospital (odds ratio [OR]: 1.90, 95% confidence interval [CI]: 1.47–2.45) and have a longer average length of stay (incidence rate ratio: 1.10, 95% CI: 1.09–1.10). Black women also were more likely to have a cesarean delivery (OR: 1.12, 95% CI 1.12–1.13) than white women. These results largely held in stratified analyses.

Conclusion In most insurance payers and socioeconomic strata, race/ethnicity alone is a factor that predicts parturient outcomes.

• References

• 1 Bryant AS, Worjoloh A, Caughey AB, Washington AE. Racial/ethnic disparities in obstetric outcomes and care: prevalence and determinants. Am J Obstet Gynecol 2010; 202 (04) 335-343
  CrossrefPubMedGoogle Scholar
• 2 Harper M, Dugan E, Espeland M, Martinez-Borges A, Mcquellon C. Why African-American women are at greater risk for pregnancy-related death. Ann Epidemiol 2007; 17 (03) 180-185
  CrossrefPubMedGoogle Scholar
• 3 Somer SJH, Sinkey RG, Bryant AS. Epidemiology of Racial/Ethnic Disparities in Severe Maternal Morbidity and Mortality. Paper presented at Seminars in perinatology; 2017
  PubMedGoogle Scholar
• 4 Cabacungan ET, Ngui EM, McGinley EL. Racial/ethnic disparities in maternal morbidities: a statewide study of labor and delivery hospitalizations in Wisconsin. Matern Child Health J 2012; 16 (07) 1455-1467
  CrossrefPubMedGoogle Scholar
• 5 Creanga AA, Bateman BT, Kuklina EV, Callaghan WM. Racial and ethnic disparities in severe maternal morbidity: a multistate analysis, 2008-2010. Am J Obstet Gynecol 2014; 210 (05) 435.e1-435.e8
  CrossrefPubMedGoogle Scholar
• 6 Shahul S, Tung A, Minhaj M. , et al. Racial disparities in comorbidities, complications, and maternal and fetal outcomes in women with preeclampsia/eclampsia. Hypertens Pregnancy 2015; 34 (04) 506-515
  CrossrefPubMedGoogle Scholar
• 7 Shen JJ, Tymkow C, MacMullen N. Disparities in maternal outcomes among four ethnic populations. Ethn Dis 2005; 15 (03) 492-497
  PubMedGoogle Scholar
• 8 Goffman D, Madden RC, Harrison EA, Merkatz IR, Chazotte C. Predictors of maternal mortality and near-miss maternal morbidity. J Perinatol 2007; 27 (10) 597-601
  CrossrefPubMedGoogle Scholar
• 9 Fang J, Madhavan S, Alderman MH. Maternal mortality in New York City: excess mortality of black women. J Urban Health 2000; 77 (04) 735-744
  CrossrefPubMedGoogle Scholar
• 10 Lo JO, Mission JF, Caughey AB. Hypertensive disease of pregnancy and maternal mortality. Curr Opin Obstet Gynecol 2013; 25 (02) 124-132
  CrossrefPubMedGoogle Scholar
• 11 Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Race, ethnicity, and nativity differentials in pregnancy-related mortality in the United States: 1993-2006. Obstet Gynecol 2012; 120 (2 Pt 1): 261-268
  CrossrefPubMedGoogle Scholar
• 12 Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality in the United States, 1998 to 2005. Obstet Gynecol 2010; 116 (06) 1302-1309
  CrossrefPubMedGoogle Scholar
• 13 Creanga AA, Berg CJ, Ko JY. , et al. Maternal mortality and morbidity in the United States: where are we now?. J Womens Health (Larchmt) 2014; 23 (01) 3-9
  CrossrefPubMedGoogle Scholar
• 14 Lang CT, King JC. Maternal mortality in the United States. Best Pract Res Clin Obstet Gynaecol 2008; 22 (03) 517-531
  CrossrefPubMedGoogle Scholar
• 15 Tucker MJ, Berg CJ, Callaghan WM, Hsia J. The Black-White disparity in pregnancy-related mortality from 5 conditions: differences in prevalence and case-fatality rates. Am J Public Health 2007; 97 (02) 247-251
  CrossrefPubMedGoogle Scholar
• 16 Aron DC, Gordon HS, DiGiuseppe DL, Harper DL, Rosenthal GE. Variations in risk-adjusted cesarean delivery rates according to race and health insurance. Med Care 2000; 38 (01) 35-44
  CrossrefPubMedGoogle Scholar
• 17 Witt WP, Wisk LE, Cheng ER. , et al. Determinants of cesarean delivery in the US: a lifecourse approach. Matern Child Health J 2015; 19 (01) 84-93
  CrossrefPubMedGoogle Scholar
• 18 Braveman P, Egerter S, Edmonston F, Verdon M. Racial/ethnic differences in the likelihood of cesarean delivery, California. Am J Public Health 1995; 85 (05) 625-630
  CrossrefPubMedGoogle Scholar
• 19 Zhang J, Troendle J, Reddy UM. , et al; Consortium on Safe Labor. Contemporary cesarean delivery practice in the United States. Am J Obstet Gynecol 2010; 203 (04) 326.e1-326.e10
  CrossrefPubMedGoogle Scholar
• 20 Chung JH, Garite TJ, Kirk AM, Hollard AL, Wing DA, Lagrew DC. Intrinsic racial differences in the risk of cesarean delivery are not explained by differences in caregivers or hospital site of delivery. Am J Obstet Gynecol 2006; 194 (05) 1323-1328
  CrossrefPubMedGoogle Scholar
• 21 Coffey RM, Andrews RM, Moy E. Racial, ethnic, and socioeconomic disparities in estimates of AHRQ patient safety indicators. Med Care 2005; 43 (3, Suppl): I48-I57
  PubMedGoogle Scholar
• 22 Kabir AA, Pridjian G, Steinmann WC, Herrera EA, Khan MM. Racial differences in cesareans: an analysis of U.S. 2001 National Inpatient Sample Data. Obstet Gynecol 2005; 105 (04) 710-718
  CrossrefPubMedGoogle Scholar
• 23 Roth LM, Henley MM. Unequal motherhood: racial-ethnic and socioeconomic disparities in cesarean sections in the United States. Soc Probl 2012; 59 (02) 207-227
  CrossrefPubMedGoogle Scholar
• 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 (04) 422.e1-422.e7
  CrossrefPubMedGoogle Scholar
• 25 Huesch M, Doctor JN. Factors associated with increased cesarean risk among African American women: evidence from California, 2010. Am J Public Health 2015; 105 (05) 956-962
  CrossrefPubMedGoogle Scholar
• 26 American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 394, December 2007. Cesarean delivery on maternal request. Obstet Gynecol 2007; 110 (06) 1501
  CrossrefPubMedGoogle Scholar
• 27 Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS. ; Maternal Health Study Group of the Canadian Perinatal Surveillance System. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ 2007; 176 (04) 455-460
  CrossrefPubMedGoogle Scholar
• 28 Aseltine Jr RH, Yan J, Fleischman S, Katz M, DeFrancesco M. Racial and ethnic disparities in hospital readmissions after delivery. Obstet Gynecol 2015; 126 (05) 1040-1047
  CrossrefPubMedGoogle Scholar
• 29 ACOG Committee Opinion No. 649: racial and ethnic disparities in obstetrics and gynecology. Obstet Gynecol 2015; 126 (06) e130-e134
  CrossrefPubMedGoogle Scholar
• 30 Harrell CJP, Burford TI, Cage BN. , et al. Multiple pathways linking racism to health outcomes. Du Bois Rev 2011; 8 (01) 143-157
  CrossrefPubMedGoogle Scholar
• 31 Gee GC, Walsemann KM, Brondolo E. A life course perspective on how racism may be related to health inequities. Am J Public Health 2012; 102 (05) 967-974
  CrossrefPubMedGoogle Scholar
• 32 Giscombé CL, Lobel M. Explaining disproportionately high rates of adverse birth outcomes among African Americans: the impact of stress, racism, and related factors in pregnancy. Psychol Bull 2005; 131 (05) 662-683
  CrossrefPubMedGoogle Scholar
• 33 Hardeman RR, Medina EM, Kozhimannil KB. Structural racism and supporting black lives - the role of health professionals. N Engl J Med 2016; 375 (22) 2113-2115
  CrossrefPubMedGoogle Scholar
• 34 Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet 2017; 389 (10077): 1453-1463
  CrossrefPubMedGoogle Scholar
• 35 Krieger N. Discrimination and health inequities. Int J Health Serv 2014; 44 (04) 643-710
  CrossrefPubMedGoogle Scholar
• 36 Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav 1995; (Spec No): 80-94
  PubMedGoogle Scholar
• 37 Grimm K, Moore L, Scanlon K. Access to health food retailers—Unites States, 2011. CDC Health Disparities and Inequalities Report—United States, 2013. Morbidity Mortality Weekly Report 2013; 62 (03) 20-26
  PubMedGoogle Scholar
• 38 Barnett JC, Berchick ER. Health Insurance Coverage in the United States: 2016. Current Population Reports 2017. Available at: https://www.census.gov/content/dam/Census/library/publications/2017/demo/p60-260.pdf . Accessed March 14, 2018
  PubMedGoogle Scholar
• 39 Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA 2000; 283 (19) 2579-2584
  CrossrefPubMedGoogle Scholar
• 40 Crear-Perry J. Systems and Policies Driving Black Maternal Health. Oral presentation at: 2018 New York Maternal Mortality Summit; February, 2018; New York, NY
  PubMed
• 41 Smedley BD. The lived experience of race and its health consequences. Am J Public Health 2012; 102 (05) 933-935
  CrossrefPubMedGoogle Scholar
• 42 Pickett KE, Collins Jr JW, Masi CM, Wilkinson RG. The effects of racial density and income incongruity on pregnancy outcomes. Soc Sci Med 2005; 60 (10) 2229-2238
  CrossrefPubMedGoogle Scholar
• 43 Williams DR. Race, socioeconomic status, and health. The added effects of racism and discrimination. Ann N Y Acad Sci 1999; 896 (01) 173-188
  CrossrefPubMedGoogle Scholar
• 44 HCUP State Inpatient Databases (SID). Healthcare Cost and Utilization Project (HCUP): 2007–2014. Rockville, MD: Agency for Healthcare Research and Quality. Available at: https://www.hcup-us.ahrq.gov/sidoverview.jsp
  PubMedGoogle Scholar
• 45 Bateman BT, Mhyre JM, Hernandez-Diaz S. , et al. Development of a comorbidity index for use in obstetric patients. Obstet Gynecol 2013; 122 (05) 957-965
  CrossrefPubMedGoogle Scholar
• 46 Metcalfe A, Lix LM, Johnson JA. , et al. Validation of an obstetric comorbidity index in an external population. BJOG 2015; 122 (13) 1748-1755
  CrossrefPubMedGoogle Scholar
• 47 Cheesman K, Brady JE, Flood P, Li G. Epidemiology of anesthesia-related complications in labor and delivery, New York State, 2002-2005. Anesth Analg 2009; 109 (04) 1174-1181
  CrossrefPubMedGoogle Scholar
• 48 Tanner LD, Chen H-Y, Chauhan SP, Sibai BM. 944: Racial disparity in length of stay after scheduled cesarean delivery. Am J Obstet Gynecol 2018; 218 (01) S559-S560
  CrossrefPubMedGoogle Scholar
• 49 Weiss M, Ryan P, Lokken L, Nelson M. Length of stay after vaginal birth: sociodemographic and readiness-for-discharge factors. Birth 2004; 31 (02) 93-101
  CrossrefPubMedGoogle Scholar
• 50 Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol 2011; 118 (01) 29-38
  CrossrefPubMedGoogle Scholar
• 51 Boyle A, Reddy UM. Epidemiology of cesarean delivery: the scope of the problem. Semin Perinatol 2012; 36 (05) 308-314
  CrossrefPubMedGoogle Scholar
• 52 Metz TD, Allshouse AA, Gilbert SAB, Doyle R, Tong A, Carey JC. Variation in primary cesarean delivery rates by individual physician within a single-hospital laborist model. Am J Obstet Gynecol 2016; 214 (04) 531.e1-531.e6
  CrossrefPubMedGoogle Scholar
• 53 Yasmeen S, Romano PS, Schembri ME, Keyzer JM, Gilbert WM. Accuracy of obstetric diagnoses and procedures in hospital discharge data. Am J Obstet Gynecol 2006; 194 (04) 992-1001
  CrossrefPubMedGoogle Scholar
• 54 Goff SL, Pekow PS, Markenson G, Knee A, Chasan-Taber L, Lindenauer PK. Validity of using ICD-9-CM codes to identify selected categories of obstetric complications, procedures and co-morbidities. Paediatr Perinat Epidemiol 2012; 26 (05) 421-429
  CrossrefPubMedGoogle Scholar
• 55 Williams DR, Mohammed SA. Discrimination and racial disparities in health: evidence and needed research. J Behav Med 2009; 32 (01) 20-47
  CrossrefPubMedGoogle Scholar
• 56 Bonilla-Silva E. Rethinking racism: toward a structural interpretation. Am Sociol Rev 1997; 62 (03) 465-480
  CrossrefPubMedGoogle Scholar
• 57 Vasudevan C, Renfrew M, McGuire W. Fetal and perinatal consequences of maternal obesity. Arch Dis Child Fetal Neonatal Ed 2011; 96 (05) F378-F382
  CrossrefPubMedGoogle Scholar
• 58 Sheiner E, Levy A, Menes TS, Silverberg D, Katz M, Mazor M. Maternal obesity as an independent risk factor for caesarean delivery. Paediatr Perinat Epidemiol 2004; 18 (03) 196-201
  CrossrefPubMedGoogle Scholar
• 59 Denison FC, Norwood P, Bhattacharya S. , et al. Association between maternal body mass index during pregnancy, short-term morbidity, and increased health service costs: a population-based study. BJOG 2014; 121 (01) 72-81
  CrossrefPubMedGoogle Scholar
• 60 Doherty DA, Magann EF, Francis J, Morrison JC, Newnham JP. Pre-pregnancy body mass index and pregnancy outcomes. Int J Gynaecol Obstet 2006; 95 (03) 242-247
  CrossrefPubMedGoogle Scholar
• 61 Bhattacharya S, Campbell DM, Liston WA, Bhattacharya S. Effect of Body Mass Index on pregnancy outcomes in nulliparous women delivering singleton babies. BMC Public Health 2007; 7 (01) 168
  CrossrefPubMedGoogle Scholar
• 62 Allison PD. Missing Data: Sage University Papers Series on Quantitative Applications in the Social Sciences (07–136). Thousand Oaks, CA; 2001
  Google Scholar
• 63 Kozhimannil KB, Law MR, Virnig BA. Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues. Health Aff (Millwood) 2013; 32 (03) 527-535
  CrossrefPubMedGoogle Scholar
• 64 Little SE, Orav EJ, Robinson JN, Caughey AB, Jha AK. The relationship between variations in cesarean delivery and regional health care use in the United States. Am J Obstet Gynecol 2016; 214 (06) 735.e1-735.e8
  CrossrefPubMedGoogle Scholar
• 65 2010. March 23, The Patient Protection and Affordable Care Act (PPACA), Pub. L. No. 111-148, 124 Stat. 119
  PubMed