Dataset Information

Race and Ethnicity, Medical Insurance, and Within-Hospital Severe Maternal Morbidity Disparities.

ABSTRACT:

Objective

To examine within-hospital racial and ethnic disparities in severe maternal morbidity rates and determine whether they are associated with differences in types of medical insurance.

Methods

We conducted a population-based, cross-sectional study using linked 2010-2014 New York City discharge and birth certificate data sets (N=591,455 deliveries) to examine within-hospital black-white, Latina-white, and Medicaid-commercially insured differences in severe maternal morbidity. We used logistic regression to produce risk-adjusted rates of severe maternal morbidity for patients with commercial and Medicaid insurance and for black, Latina, and white patients within each hospital. We compared these within-hospital adjusted rates using paired t-tests and conditional logit models.

Results

Severe maternal morbidity was higher among black and Latina women than white women (4.2% and 2.9% vs 1.5%, respectively, P<.001) and among women insured by Medicaid than those commercially insured (2.8% vs 2.0%, P<.001). Women insured by Medicaid compared with those with commercial insurance had similar risk for severe maternal morbidity within the same hospital (P=.54). In contrast, black women compared with white women had significantly higher risk for severe maternal morbidity within the same hospital (P<.001), as did Latina women (P<.001). Conditional logit analyses confirmed these findings, with black and Latina women compared with white women having higher risk for severe maternal morbidity (adjusted odds ratio [aOR] 1.52; 95% CI 1.46-1.62 and aOR 1.44; 95% CI 1.36-1.53, respectively) and women insured by Medicaid compared with those commercially insured having similar risk.

Conclusion

Within hospitals in New York City, black and Latina women are at higher risk of severe maternal morbidity than white women; this is not associated with differences in types of insurance.

SUBMITTER: Howell EA

PROVIDER: S-EPMC7117864 | biostudies-literature | 2020 Feb

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:Hospital discharge (HD) records contain important information that is used in public health and health care sectors. It is becoming increasingly common to rely mostly or exclusively on HD data to assess and monitor severe maternal morbidity (SMM) overall and by sociodemographic characteristics, including race and ethnicity. Limited studies have validated race and ethnicity in HD or provided estimates on the impact of assessing health differences in maternity populations. This study aims to determine the differences in race and ethnicity reporting between HD and birth certificate (BC) data for maternity hospitals in Florida and to estimate the impact of race and ethnicity misclassification on state- and hospital-specific SMM rates. We conducted a population-based retrospective study of live births using linked BC and HD records from 2016 to 2019 (n = 783,753). BC data were used as the gold standard. Race and ethnicity were categorized as non-Hispanic (NH)-White, NH-Black, Hispanic, NH-Asian Pacific Islander (API), and NH-American Indian or Alaskan Native (AIAN). Overall, race and ethnicity misclassification and its impact on SMM at the state- and hospital levels were estimated. At the state level, NH-AIAN women were the most misclassified (sensitivity: 28.2%; positive predictive value (PPV): 25.2%) and were commonly classified as NH-API (30.3%) in HD records. NH-API women were the next most misclassified (sensitivity: 57.3%; PPV: 85.4%) and were commonly classified as NH-White (5.8%) or NH-other (5.5%). At the hospital level, wide variation in sensitivity and PPV with negative skewing was identified, particularly for NH-White, Hispanic, and NH-API women. Misclassification did not result in large differences in SMM rates at the state level for all race and ethnicity categories except for NH-AIAN women (% difference 78.7). However, at the hospital level, Hispanic women had wide variability of a percent difference in SMM rates and were more likely to have underestimated SMM rates. Reducing race and ethnicity misclassification on HD records is key in assessing and addressing SMM differences and better informing surveillance, research, and quality improvement efforts.

Project description:BackgroundSevere maternal morbidity and mortality are increasing in the United States with continued healthcare disparities among Non-Hispanic Black women. However, there is sparse data on the disparities of severe maternal morbidity and mortality by race/ethnicity as it relates to community type.ObjectiveTo determine whether residing in rural communities increases the racial/ethnic disparities in severe maternal morbidity and mortality.DesignThis study is a cross-sectional analysis of women admitted for delivery from 2015 to 2020. A total of 204,140 adults who self-identified as women, were admitted for delivery, who resided in Maryland, and were between the ages 15 and 54 were included in our analysis. Community type was defined as either rural or urban.MethodsA multivariable logistic regression, which included an interaction term between race/ethnicity and community type, was used to assess the effect of community type on the relationship between race/ethnicity and severe maternal morbidity and mortality. Data were obtained from the Maryland Health Service Cost Review Commission database. The primary outcome was a composite, binary variable of severe maternal morbidity and mortality. Exposures of interest were residence in either rural or urban counties in Maryland and race/ethnicity.ResultsOur study found that after adjusting for confounders, odds of severe maternal morbidity and mortality were 65% higher in Non-Hispanic Black women (odds ratio 1.65, 95% confidence interval: 1.46-1.88, p < 0.001) and 54% higher in Non-Hispanic Asian women (odds ratio 1.54, 95% confidence interval: 1.24-1.90, p < 0.001) compared to Non-Hispanic White women. The interaction term used to determine whether community type modified the relationship between race/ethnicity and severe maternal morbidity and mortality was not statistically significant for any race/ethnicity (Non-Hispanic Black women, p = 0.60; Non-Hispanic Asian women, p = 0.91; Hispanic women, p = 0.15; Other/Unknown race/ethnicity, p = 0.54).ConclusionAlthough our study confirmed the known disparities in maternal outcomes by race/ethnicity, we found that residing in rural communities did not increase racial/ethnic disparities.

Project description:OBJECTIVE:To estimate whether severe maternal morbidity is associated with increased risk of psychiatric illness in the year after delivery hospital discharge. METHODS:This retrospective cohort study used International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes within Florida's Healthcare Cost and Utilization Project's databases. The first liveborn singleton delivery from 2005 to 2015 was included; women with ICD-9-CM codes for psychiatric illness or substance use disorder during pregnancy were excluded. The exposure was ICD-9-CM codes during delivery hospitalization of severe maternal morbidity, as per the Centers for Disease Control and Prevention. The primary outcome was ICD-9-CM codes in emergency department encounter or inpatient admission within 1 year of hospital discharge of composite psychiatric morbidity (suicide attempt, depression, anxiety, posttraumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder). The secondary outcome was a composite of ICD-9-CM codes for substance use disorder. We compared women with severe maternal morbidity with those without severe maternal morbidity using multivariable logistic regression adjusting for sociodemographic factors and medical comorbidities. Cox proportional hazard models identified the highest risk period after hospital discharge for the primary outcome. RESULTS:A total of 15,510 women with severe maternal morbidity and 1,178,458 without severe maternal morbidity were included. Within 1 year of hospital discharge, 2.9% (n=452) of women with severe maternal morbidity had the primary outcome compared with 1.6% (n=19,279) of women without severe maternal morbidity, resulting in an adjusted odds ratio (aOR) 1.74 (95% CI 1.58-1.91). The highest risk interval was within 4 months of discharge (adjusted hazard ratio [adjusted HR] 2.53 [95% CI 2.05-3.12]). Most severe maternal morbidity conditions were associated with higher risk of postpartum psychiatric illness. Women with severe maternal morbidity had nearly twofold higher risk of postpartum substance use disorder (170 [1.1%] vs 6,861 [0.6%]; aOR 1.91 [95% CI 1.64-2.23]). CONCLUSION:Though absolute numbers were modest, severe maternal morbidity was associated with increased risk of severe postpartum psychiatric morbidity and substance use disorder. The highest period of risk extended to 4 months after hospital discharge.

Project description:Objectiveto analyse the impact of in-hospital care on severe maternal morbidity using WHO's near-miss approach in the low-resource, high mortality setting of Zanzibar's referral hospital.SettingMnazi Mmoja Hospital, a tertiary care facility, in Zanzibar, Tanzania.MethodsWe identified all cases of morbidity and mortality in women admitted within 42 days after the end of pregnancy at Mnazi Mmoja Hospital in the period from April to October 2016. The severity of complications was classified using WHO's near-miss approach definitions: potentially life-threatening condition (PLTC), maternal near-miss (MNM) or maternal death (MD). Quality of in-hospital care was assessed using the mortality index (MI) defined as ratio between mortality and severe maternal outcome (SMO) where SMO = MD + MNM, cause-specific case facility rates and comparison with predicted mortality based on the Maternal Severity Index model.Main outcomes5551 women were included. 569 (10.3%) had a potentially life-threatening condition and 65 (1.2%) a severe maternal outcome (SMO): 37 maternal near-miss cases and 28 maternal deaths. The mortality index was high at 0.43 and similar for women who developed a SMO within 12 hours of admission and women who developed a SMO after 12 hours. A standardized mortality ratio of 6.03 was found; six times higher than that expected in moderate maternal mortality settings given the same severity of cases. Obstetric haemorrhage was found to be the main cause of SMO. Ruptured uterus and admission to ICU had the highest case-fatality rates. Maternal death cases seemed to have received essential interventions less often.ConclusionsWHO's near-miss approach can be used in this setting. The high mortality index observed shows that in-hospital care is not preventing progression of disease adequately once a severe complication occurs. Almost one in two women experiencing life-threatening complications will die. This is six times higher than in moderate mortality settings.

Project description:ObjectiveTo investigate differences in severe maternal morbidity between Hispanic mothers and three major Hispanic subgroups compared with non-Hispanic white mothers and the extent to which differences in delivery hospitals may contribute to excess morbidity among Hispanic mothers.MethodsWe conducted a population-based cross-sectional study using linked 2011-2013 New York City discharge and birth certificate data sets (n=353,773). Rates of severe maternal morbidity were calculated using a published algorithm based on diagnosis and procedure codes. Mixed-effects logistic regression with a random hospital-specific intercept was used to generate risk-standardized severe maternal morbidity rates for each hospital taking into consideration patient sociodemographic characteristics and comorbidities. Differences in the distribution of Hispanic and non-Hispanic white deliveries were assessed among these hospitals in relation to their risk-adjusted morbidity. Sensitivity analyses were conducted after excluding isolated blood transfusion from the morbidity composite.ResultsSevere maternal morbidity occurred in 4,541 deliveries and was higher among Hispanic than non-Hispanic white women (2.7% compared with 1.5%, P<.001); this rate was 2.9% among those who were Puerto Rican, 2.7% among those who were foreign-born Dominican, and 3.3% among those who were foreign-born Mexican. After adjustment for patient characteristics, the risk remained elevated for Hispanic women (odds ratio [OR] 1.42, 95% confidence interval [CI] 1.22-1.66) and for all three subgroups compared with non-Hispanic white women (P<.001). Risk for Hispanic women was attenuated in sensitivity analyses (OR 1.17, 95% CI 1.02-1.33). Risk-standardized morbidity across hospitals varied sixfold. We estimate that Hispanic-non-Hispanic white differences in delivery location may contribute up to 37% of the ethnic disparity in severe maternal morbidity rates in New York City hospitals.ConclusionHispanic compared with non-Hispanic white mothers are more likely to deliver at hospitals with higher risk-adjusted severe maternal morbidity rates and these differences in site of delivery may contribute to excess morbidity among Hispanic mothers. Our results suggest improving quality at the lowest performing hospitals could benefit both non-Hispanic white and Hispanic women and reduce ethnic disparities in severe maternal morbidity rates.

Project description:ObjectivesTo assess the scale of ethnic inequalities in severe maternal morbidity (SMM) rates and quantify the contribution of maternal characteristics to these disparities.DesignRetrospective cohort study.SettingWhole-of-population linked administrative data from 2002 to 2015 in Western Australia.ParticipantsWomen with 410 043 birth events (includes all births from the same pregnancy) of 20 weeks' or more gestation, including terminations for congenital anomalies.Primary and secondary outcome measuresWomen with SMM were identified based on a composite indicator of SMM using diagnosis and procedure codes developed for use in routinely collected data. Mothers were classified into seven ethnic groups, based on their reported ethnic origin. The associations between maternal ethnic origin and SMM were examined using a log-binomial model, which estimates risk ratios (RRs) and 95% CIs. The Blinder-Oaxaca decomposition technique was employed to partition the disparity in SMM between Aboriginal and Caucasian populations into 'explained' and 'unexplained' components.ResultsDuring the study period, 9378 SMM cases were documented. In the adjusted model, Aboriginal (RR 1.73, 95% CI 1.59 to 1.87), African (RR 1.64, 95% CI 1.43 to 1.89) and 'other' ethnicity (RR 1.49, 95% CI 1.37 to 1.63) women were at significantly higher risk of SMM compared with Caucasian women. Teenage and older mothers and socioeconomically disadvantaged women were also at greater risk of SMM. Differences in sociodemographic characteristics explained 33.2% of the disparity in SMM between Aboriginal and Caucasian women.ConclusionsThere are distinct disparities in SMM by ethnicity in Western Australia, with a greater risk among Aboriginal and African women. While improvements in SES and a reduction in teenage pregnancy can potentially support a sizeable reduction in SMM rate inequalities, future research should investigate other potential pathways and targeted interventions to close the ethnicity disparity.