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Murosko DC, Radack J, Barreto A, Passarella M, Formanowski B, McGann C, Nelin T, Paul K, Peña MM, Salazar EG, Burris HH, Handley SC, Montoya-Williams D, Lorch SA. County-level Structural Vulnerabilities in Maternal Health and Geographic Variation in Infant Mortality. J Pediatr 2024:114274. [PMID: 39216622 DOI: 10.1016/j.jpeds.2024.114274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/15/2024] [Accepted: 08/26/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE To evaluate whether community factors that differentially affect the health of pregnant people contribute to geographic differences in infant mortality across the United States. STUDY DESIGN This retrospective cohort study sought to characterize the association of a novel composite measure of county-level maternal structural vulnerabilities, the Maternal Vulnerability Index (MVI), with risk of infant death. We evaluated 11,456,232 singleton infants born at 22 0/7 through 44 6/7 weeks' gestation from 2012 to 2014. Using county-level MVI, which ranges from 0-100, multivariable mixed effects logistic regression models quantified associations per 20-point increment in MVI, with odds of death clustered at the county level and adjusted for state, maternal, and infant covariates. Secondary analyses stratified by the social, physical, and health exposures that comprise the overall MVI score. Outcome was also stratified by cause of death. RESULTS Odds of death were higher among infants from counties with the greatest maternal vulnerability (0.62% in highest quintile vs 0.32% in lowest quintile, [p<0.001]). Odds of death increased 6% per 20-point increment in MVI (aOR: 1.06, 95% CI 1.04, 1.07). The effect estimate was highest with theme of mental health and substance use (aOR 1.08; 95% CI 1.06, 1.09). Increasing vulnerability was associated with six of seven causes of death. CONCLUSIONS Community-level social, physical, and healthcare determinants indicative of maternal vulnerability may explain some of the geographic variation in infant death, regardless of cause of death. Interventions targeted to county-specific maternal vulnerabilities may reduce infant mortality.
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Affiliation(s)
- Daria C Murosko
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania.
| | - Josh Radack
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alejandra Barreto
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Molly Passarella
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brielle Formanowski
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Carolyn McGann
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Timothy Nelin
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Kathryn Paul
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - Michelle-Marie Peña
- Division of Neonatology, Children's Healthcare of Atlanta and Emory University School of Medicine. Atlanta, GA
| | - Elizabeth G Salazar
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Heather H Burris
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sara C Handley
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Diana Montoya-Williams
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott A Lorch
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Hesson AM, Davuluri K, Corbin CK, Rujan AM, Berman DR. There's no place like home: optimizing the antepartum inpatient experience. Matern Health Neonatol Perinatol 2024; 10:15. [PMID: 39085946 PMCID: PMC11293146 DOI: 10.1186/s40748-024-00185-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 06/18/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND To characterize the demographics of a modern hospitalized antepartum population, compare the morbidities of this subset to national morbidity trends, and identify predictors of satisfaction during hospitalization to inform opportunities to enhance equitable antepartum care. METHODS Pregnant people admitted to the antepartum service of a large university hospital between 2011 and 2019 were surveyed about their hospitalization, pregnancy outcomes, provider interactions, perceived needs, and resource use. Multiple correspondence analysis was used to group patient responses based on latent relationships among demographic, medical, and psychosocial variables. Multivariate analyses were conducted to identify predictors of patient experience rating. Patient free text responses were qualitatively analyzed for common themes. RESULTS Of 740 pregnant people invited to participate, 298 surveys met criteria for analysis. 25.2% of these pregnant people identified as non-white and 20.8% were admitted for the management of a chronic medical condition. Patient responses clustered into three representative groups: (1) working pregnant people facing resource limitations, (2) first-time pregnant people with college educations, and (3) pregnant people with medical problems and limited partner support. The mean overall patient admission experience rating was 8.4 ± 1.7 out of 10. Variables represented in Cluster 1 (working and resource limitations) were associated with lower patient experience rating (p < 0.01). There was no significant variation in experience rating with indication for admission (P = 0.14) or outcome of the pregnancy (P = 0.32). Conversely, feeling supported by partners (P < 0.01) and providers (P < 0.01) directly correlated with a better experience. CONCLUSION Black pregnant people and those with chronic medical conditions are overrepresented in this antepartum population when compared to the demographics of those not requiring hospitalization in pregnancy, where these groups also have higher rates of maternal morbidity and mortality at the national level. The most important contributors to patients' satisfaction with their antepartum experience are feeling listened to by providers and supported by partners. Improving patient-provider communication and partner engagement during antepartum admissions should be a focus of inpatient high-risk obstetric care.
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Affiliation(s)
- Ashley M Hesson
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Michigan, 1500 East Medical Center Dr, Ann Arbor, MI, 48109, USA.
| | - Kavya Davuluri
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Michigan, 1500 East Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - C Kenzie Corbin
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Michigan, 1500 East Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Anna M Rujan
- Department of Obstetrics & Gynecology, Northwestern University, Chicago, IL, USA
| | - Deborah R Berman
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Michigan, 1500 East Medical Center Dr, Ann Arbor, MI, 48109, USA
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Vesoulis ZA, Diggs S, Brackett C, Sullivan B. Racial and geographic disparities in neonatal brain care. Semin Perinatol 2024; 48:151925. [PMID: 38897830 DOI: 10.1016/j.semperi.2024.151925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
In this review, we explore race-based disparities in neonatology and their impact on brain injury and neurodevelopmental outcomes. We discuss the historical context of healthcare discrimination, focusing on the post-Civil War era and the segregation of healthcare facilities. We highlight the increasing disparity in infant mortality rates between Black and White infants, with premature birth being a major contributing factor, and emphasize the role of prenatal factors such as metabolic syndrome and toxic stress in affecting neonatal health. Furthermore, we examine the geographic and historical aspects of racial disparities, including the consequences of redlining and limited access to healthcare facilities or nutritious food options in Black communities. Finally, we delve into the higher incidence of brain injuries in Black neonates, as well as disparities in adverse neurodevelopmental outcome. This evidence underscores the need for comprehensive efforts to address systemic racism and provide equitable access to healthcare resources.
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Affiliation(s)
- Zachary A Vesoulis
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO, USA.
| | - Stephanie Diggs
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Cherise Brackett
- Department of Pediatrics, Division of Neonatology, University of Virginia, USA
| | - Brynne Sullivan
- Department of Pediatrics, Division of Neonatology, University of Virginia, USA
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Shukla VV, Youngblood EM, Tindal RR, Carlo WA, Travers CP. Persistent disparities in black infant mortality across gestational ages in the United States. J Perinatol 2024; 44:584-586. [PMID: 38160225 DOI: 10.1038/s41372-023-01863-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 12/06/2023] [Accepted: 12/15/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Vivek V Shukla
- University of Alabama at Birmingham, Division of Neonatology, Birmingham, AL, USA.
| | - Emily M Youngblood
- University of Alabama at Birmingham, Division of Neonatology, Birmingham, AL, USA
| | - Rachel R Tindal
- University of Alabama at Birmingham, Division of Neonatology, Birmingham, AL, USA
| | - Waldemar A Carlo
- University of Alabama at Birmingham, Division of Neonatology, Birmingham, AL, USA
| | - Colm P Travers
- University of Alabama at Birmingham, Division of Neonatology, Birmingham, AL, USA
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Johnson DL, Carlo WA, Rahman AKMF, Tindal R, Trulove SG, Watt MJ, Travers CP. Health Insurance and Differences in Infant Mortality Rates in the US. JAMA Netw Open 2023; 6:e2337690. [PMID: 37831450 PMCID: PMC10576209 DOI: 10.1001/jamanetworkopen.2023.37690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/01/2023] [Indexed: 10/14/2023] Open
Abstract
Importance Health insurance status is associated with differences in access to health care and health outcomes. Therefore, maternal health insurance type may be associated with differences in infant outcomes in the US. Objective To determine whether, among infants born in the US, maternal private insurance compared with public Medicaid insurance is associated with a lower infant mortality rate (IMR). Design, Setting, and Participants This cohort study used data from the Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research expanded linked birth and infant death records database from 2017 to 2020. Hospital-born infants from 20 to 42 weeks of gestational age were included if the mother had either private or Medicaid insurance. Infants with congenital anomalies, those without a recorded method of payment, and those without either private insurance or Medicaid were excluded. Data analysis was performed from June 2022 to August 2023. Exposures Private vs Medicaid insurance. Main Outcomes and Measures The primary outcome was the IMR. Negative-binomial regression adjusted for race, sex, multiple birth, any maternal pregnancy risk factors (as defined by the CDC), education level, and tobacco use was used to determine the difference in IMR between private and Medicaid insurance. The χ2 or Fisher exact test was used to compare differences in categorical variables between groups. Results Of the 13 562 625 infants included (6 631 735 girls [48.9%]), 7 327 339 mothers (54.0%) had private insurance and 6 235 286 (46.0%) were insured by Medicaid. Infants born to mothers with private insurance had a lower IMR compared with infants born to those with Medicaid (2.75 vs 5.30 deaths per 1000 live births; adjusted relative risk [aRR], 0.81; 95% CI, 0.69-0.95; P = .009). Those with private insurance had a significantly lower risk of postneonatal mortality (0.81 vs 2.41 deaths per 1000 births; aRR, 0.57; 95% CI, 0.47-0.68; P < .001), low birth weight (aRR, 0.90; 95% CI, 0.85-0.94; P < .001), vaginal breech delivery (aRR, 0.80; 95% CI, 0.67-0.96; P = .02), and preterm birth (aRR, 0.92; 95% CI, 0.88-0.97; P = .002) and a higher probability of first trimester prenatal care (aRR, 1.24; 95% CI, 1.21-1.27; P < .001) compared with those with Medicaid. Conclusions and Relevance In this cohort study, maternal Medicaid insurance was associated with increased risk of infant mortality at the population level in the US. Novel strategies are needed to improve access to care, quality of care, and outcomes among women and infants enrolled in Medicaid.
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Affiliation(s)
- Desalyn L. Johnson
- University of Alabama School of Medicine, University of Alabama at Birmingham, Birmingham
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham
| | | | | | - Sarah G. Trulove
- University of Alabama School of Medicine, University of Alabama at Birmingham, Birmingham
| | - Mykaela J. Watt
- University of Alabama School of Medicine, University of Alabama at Birmingham, Birmingham
| | - Colm P. Travers
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham
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Sullivan BA, Hochheimer CJ, Chernyavskiy P, King WE, Fairchild KD. Impact of race on heart rate characteristics monitoring in very low birth weight infants. Pediatr Res 2023; 94:575-580. [PMID: 36650306 PMCID: PMC10350468 DOI: 10.1038/s41390-023-02470-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 12/14/2022] [Accepted: 12/21/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND A multicenter RCT showed that displaying a heart rate characteristics index (HRCi) predicting late-onset sepsis reduced mortality for VLBW infants. We aimed to assess whether HRCi display had a differential impact for Black versus White infants. METHODS We performed secondary data analysis of Black and White infants enrolled in the HeRO RCT. We evaluated the predictive performance of the HRCi for infants with Black or White maternal race. Using models adjusted for birth weight, we assessed outcomes and interventions for a race × randomization interaction. RESULTS Among 2607 infants, Black infants had lower birth weight, gestational age, length of stay, and ventilator days, while sepsis and mortality were similar. The HRCi performed equally for sepsis prediction in Black and White infants. We found no differential effect of randomization by race on sepsis, mortality, antibiotic days, length of stay, or ventilator days. However, there was a differential randomization effect by race for blood cultures per patient: White RR 1.11 (95% CrI 1.04-1.18), Black RR 1.00 (0.93-1.07). CONCLUSIONS The HRCi performed similarly for sepsis prediction in Black and White infants. Randomization to HRCi display increased blood cultures in White but not in Black infants, while the impact on other outcomes or interventions was similar. IMPACT Predictive analytics, such as heart rate characteristics (HRC) monitoring for late-onset neonatal sepsis, should have equal impact among patients of different race. Infants with Black or White maternal race randomized to HRC display had similar outcomes, but randomization to the study arm increased a related clinical intervention, blood cultures, in White but not in Black infants. This study provides evidence of a differential effect of predictive models on clinical care by race. The work will promote consideration and analysis of equity in the implementation of predictive analytics.
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Affiliation(s)
- Brynne A Sullivan
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | | | - Pavel Chernyavskiy
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - William E King
- Medical Predictive Sciences Corporation, Charlottesville, VA, USA
| | - Karen D Fairchild
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
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Silva ER, Shukla VV, Tindal R, Carlo WA, Travers CP. Association of Active Postnatal Care With Infant Survival Among Periviable Infants in the US. JAMA Netw Open 2023; 6:e2250593. [PMID: 36656583 PMCID: PMC9856598 DOI: 10.1001/jamanetworkopen.2022.50593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
IMPORTANCE Active postnatal care has been associated with center differences in survival among periviable infants. Regional differences in outcomes among periviable infants in the US may be associated with differences in active postnatal care. OBJECTIVE To determine if regions with higher rates of active postnatal care will have higher gestational age-specific survival rates among periviable infants. DESIGN, SETTING, AND PARTICIPANTS This cohort study included live births from 22 to 25 weeks' gestation weighing 400 to 999 g in the US Centers for Disease Control and Prevention (CDC) WONDER 2017 to 2020 (expanded) database. Infants with congenital anomalies were excluded. Active postnatal care was defined using the CDC definition of abnormal conditions of newborn as presence of any of the following: neonatal intensive care unit (NICU) admission, surfactant, assisted ventilation, antibiotics, and seizures. Data were analyzed from August to November 2022. MAIN OUTCOMES AND MEASURES Regional gestational age-specific survival rates were compared with rates of active postnatal care in the 10 US Health and Human Services regions using Kendall τ test. RESULTS We included 41 707 periviable infants, of whom 32 674 (78%) were singletons and 19 467 (46.7%) were female. Among those studied 34 983 (83.9%) had evidence of active care, and 26 009 (62.6%) survived. Regional rates of active postnatal care were positively correlated with regional survival rates at 22 weeks' gestation (rτ[8] = 0.56; r2 = 0.31; P = .03) but the correlation was not significant at 23 weeks' gestation (rτ[8] = 0.47; r2 = 0.22; P = .07). There was no correlation between active care and survival at 24 or 25 weeks' gestation. Regional rates of both NICU admission and assisted ventilation following delivery were positively correlated with regional rates of survival at 22 weeks' gestation (both P < .05). Regional rates of antenatal corticosteroids exposure were also positively correlated with regional rates of survival at 22 weeks' gestation (rτ[8] = 0.60; r2 = 0.36; P = .02). CONCLUSIONS AND RELEVANCE In this cohort study of 41 707 periviable infants, regional differences in rates of active postnatal care, neonatal intensive care unit admission, provision of assisted ventilation and antenatal corticosteroid exposure were moderately correlated with survival at 22 weeks' gestation. Further studies focused on individual-level factors associated with active periviable care are warranted.
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Affiliation(s)
- Emani R. Silva
- University of Alabama at Birmingham School of Medicine, Birmingham
| | - Vivek V. Shukla
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham
| | - Rachel Tindal
- University of Alabama at Birmingham School of Medicine, Birmingham
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham
| | - Colm P. Travers
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham
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