Racial disparities persist in obstetric care

1. Black women experienced higher rates of delivery-related complications than white or Hispanic women whether they received care at primarily white, black or Hispanic-serving hospitals. 

2. Black-serving hospitals performed worse than white-serving hospitals in 12 of 15 delivery care indicators with significantly higher rates of in-hospital mortality, puerperal cardiovascular disorders and infection, obstetric embolus and urinary tract infection. 

Evidence Rating Level: 2 (Good) 

Study Rundown: According to CDC data, pregnancy-related mortality in the United States has been rising. Since the late 1980s, the obstetric mortality rate has doubled from 7.2 per 100,000 to 17.8 per 100,000 in 2009. Experts purport this increase may be related to higher capture rate attributable to improved documentation with electronic medical records or to the H1N1 outbreak in 2009. Another potential contributor is racial disparity. Racial minorities are less likely to be insured and have lower rates of healthcare utilization. According to CDC , black women experienced three times higher pregnancy-related mortality rates than white women from 2006-2009. Previous research has examined site of care (medical and surgical safety performance in hospitals) and comparisons of outcomes at primarily white and primarily black-serving hospitals has demonstrated worse overall outcomes at black-serving hospitals. This research has not been done in regards to delivery-related complications. The present work examined data from seven different states to examine whether primarily white, primarily black or primarily Hispanic-serving hospitals differed in quality of care measures and also whether complication rates within these hospitals differed by patient ethnicity. Results demonstrate that black-serving hospitals serve a poorer community with more chronic medical conditions; they also perform worse in pregnancy related indicators compared to white-serving hospitals. In the majority of indicators and across hospital type (white-serving, black-serving and Hispanic-serving) black women experienced higher rates of delivery related problems compared to their white or Hispanic counterparts.

Strengths of this study access to a large, multi-state database that increases generalizability of results and powers analyses even after stratification by numerous covariates.Inclusion of economic and insurance data as well as co-morbidities increases validity. Limitations include statistical limitations include the novel question of site of care based on racial and ethnic differences in relation to obstetric care. Findings were limited by usage ICD-9-CM codes to determine complication rate, which introduces opportunity for bias if complications are systematically coded differently at different hospitals. Additionally, study authors defined the referent group as white women (RR=1.00) even at Hispanic and black-serving hospitals such that existent ethnicity-related differences in indicators at Hispanic and black-serving hospitals might have gone undetected.

Click to read study in AJOG

Relevant Reading: Racial and ethnic disparities in severe maternal morbidity: a multistate analysis, 2008-2010

In-Depth [cross-sectional study]: This study used the Healthcare Cost and Utilization Project’s State Inpatient Database, which includes data from hospitals Arizona, California, Florida, Michigan, New Jersey, New York and North Carolina, to analyze data from nearly 4.5 million deliveries from 2008-2011. Race/ethnicity, age, income, insurance coverage, and existing medical conditions were identified. Outcomes of interest were delivery-related indicators such as obstetric trauma, obstetric wound complications following cesarean, in-patient mortality and other morbidities. Hospitals were designated as white-serving if the majority (>50%) of deliveries occurred in non-Hispanic white women; black if >50% were in non-Hispanic black women.

In white and Hispanic-serving hospitals, non-Hispanic blacks experienced higher rates of complications compared to non-Hispanic whites on numerous indicators.  Compared to whites, black patients experienced 3 times higher risk of inpatient mortality at white-serving hospitals (RR:3.05, OR:1.80-5.15). There were few differences in complications (indicator rates) in black-serving hospitals by ethnicity. Black-serving hospitals performed worse on 12 of 15 indicators, including puerperal infection (IR: 5.58 per 1,000 CI: 5.16-6.00 at black-serving hospitals compared to IR: 1.17 CI:1.12-1.22 at white-serving hospitals).

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