Race/ethnicity, maternal educational attainment, and infant mortality in the United States

High-Risk Infant Developmental Outcome Is Associated with Medical Complexity and Neighborhood Opportunity

OBJECTIVE

To assess how medical complexity and neighborhood opportunity jointly affect cognitive, motor, and language Bayley's Scales of Infant Development. Secondary objectives involved identifying the factors contributing to developmental disparities across diverse racial and ethnic groups.

STUDY DESIGN

Electronic health records from a Southern California high-risk infant follow-up clinic were analyzed for 440 infants from 2014 through 2023 who had either had neonatal intensive care unit stays, prematurity, very low birthweight, or developmental delay risk. Medical complexity was categorized using the Pediatric Medical Complexity Algorithm (PMCA) into complex chronic (CC), noncomplex chronic (NCC), or non-chronic (NC). Neighborhood opportunity was assessed using the Child Opportunity Index 2.0 (COI). Developmental progress was tracked from ages 4 to 35.6 months.

RESULTS

Of the cohort, 56% were male, and 67% were born prematurely, with 143 NC, 115 NCC, and 182 CC cases. Developmental scores showed a progressive decline with increased medical complexity. CC infants had lower cognitive (β= -15.20, p<0.001, 95% CI: -18.75, -11.7), motor (β= -20.50, p<0.001, 95% CI: -24.25, -16.8), and language scores (β=-11.88, p<0.001, 95% CI = -15.13 to -8.6) compared with NC infants. Lower COI was linked with decreased language scores (β= -0.07, p = 0.005, 95% CI: 0.01, 0.12) but not cognitive or motor scores.

CONCLUSIONS

In high-risk infants, the adverse effects of medical complexities on developmental outcomes exceeded those of prematurity and additionally varied according to child neighborhood opportunity.

Factors associated with preventable infant mortality in 2020: a Brazilian population-based study

OBJECTIVES

to identify factors associated with preventable infant deaths, classified as neonatal and post-neonatal.

METHODS

this is an epidemiological and population-based study relating to 2020. Data from the Mortality Information System (MIS) and the preventability classification proposed in the Brazilian Health System List of Causes of Deaths Preventable by Interventions were used.

RESULTS

prematurity, living in the North and Northeast regions and the occurrence of the event at home were associated with preventable neonatal deaths. To the avoidable post-neonatal component, death outside the hospital, low maternal education and children of brown or yellow color/race were associated.

CONCLUSIONS

the main risk factor associated with preventable deaths was prematurity, in the case of neonatal death. Low maternal education and occurrence outside the hospital were associated with post-neonatal deaths.

A Model for Engaging Citizen Scientists: A Community-Partnered Research Collaboration to Address Inequities for Black Birthing People

PURPOSE

Co-creation of a citizen-science research initiative with a collaborative team of community members and university-based scientists to address regional disparities in maternal and fetal health outcomes for Black birthing people.

DESCRIPTION

Citizen scientist-led projects, where community members actively contribute to each discovery step, from setting a research agenda to collecting data and disseminating results, can extend community participatory research initiatives and help reconceptualize traditional research processes. The Pregnancy Collaborative is a citizen-science research initiative and one of nine scientific committees of The Pittsburgh Study-a longitudinal, community-partnered study designed to bring together collaborators to improve child thriving.

ASSESSMENT

Ten community members and five university-based scientists participated during all phases of developing a citizen-scientist collaboration over an initial two-and-a-half-year period. Phases include forming the Pregnancy Collaborative and group research ethics training; co-creating a research agenda grounded in shared principles; and community-partnered data collection, analysis, and dissemination. These phases produced three key co-designed products: (1) a mission and vision statement of the Pregnancy Collaborative, (2) a Collaborative-endorsed research agenda, and (3) a citizen-scientist-executed research survey.

CONCLUSION

Lessons learned from the formation of the Pregnancy Collaborative highlight the importance of equitable power distribution through bidirectional knowledge sharing and by centering intellectual effort, lived experience, and tools and resources of those affected by health inequities. Using a citizen science approach to co-designing and executing research helps us move maternal health inequity work from "research on" to "research with."

Chi-Squared Automatic Interaction Detection Decision Tree Analysis of Social Determinants for Low Birth Weight in Virginia

This study provides additional context to the literature regarding the social inequities that impact birth outcomes in Virginia using a decision tree analysis. Chi-squared automatic interaction detection data analysis (CHAID) was performed using data from the Virginia birth registry for the years 2015-2019. Birth weight was the outcome variable, while sociodemographic factors and maternity care deserts were the explanatory variables. The prevalence of low birth weight in Virginia was of 8.1%. The CHAID decision tree model demonstrated multilevel interaction among risk factors with three levels, with a total of 34 nodes. All the variables reached significance in the model, with race/ethnicity being the first major predictor variable, each category of race and ethnicity having different significant predictors, followed by prenatal care and maternal education in the next levels. These findings signify modifiable risk factors for low birth weight, in prioritizing efforts such as programs and policies. CHAID decision tree analysis provides an effective approach to detect target populations for further intervention as pathways derived from this decision tree shed light on the different predictors of high-risk population in each of the race/ethnicity demographic categories in Virginia.

Racial and ethnic disparities in severe maternal morbidity from pregnancy through 1-year postpartum

BACKGROUND

Previous studies examining racial and ethnic disparities in severe maternal morbidity (SMM) have mainly focused on intrapartum hospitalization. There is limited information regarding the racial and ethnic distribution of SMM occurring in the antepartum and postpartum periods, including SMM occurring beyond the traditional 6 weeks postpartum period.

OBJECTIVE

To examine the racial and ethnic distribution of SMM during antepartum, intrapartum, and postpartum hospitalizations through 1-year postpartum, overall and stratified by maternal sociodemographic factors, and to estimate the percent increase in SMM by race and ethnicity and maternal sociodemographic factors within each racial and ethnic group after accounting for both antepartum and postpartum SMM through 1-year postpartum rather than just SMM occurring during the intrapartum hospitalization.

STUDY DESIGN

We conducted a retrospective cohort study using birth and fetal death certificate data linked to hospital discharge records from Michigan, Oregon, and South Carolina from 2008-2020. We examined the distribution of non-transfusion SMM and total SMM per 10,000 cases during antepartum, intrapartum, and postpartum hospitalizations through 365 days postpartum by race and ethnicity and by maternal education and insurance type within each racial and ethnic group. We subsequently examined "SMM cases added" by race and ethnicity and by maternal education and insurance type within each racial and ethnic group. The "SMM cases added" represent cases among unique individuals that are identified by considering the antepartum and postpartum periods but that would be missed if only the intrapartum hospitalization cases were included.

RESULTS

Among 2,584,206 birthing individuals, a total of 37,112 (1.4%) individuals experienced non-transfusion SMM and 64,661 (2.5%) experienced any SMM during antepartum, intrapartum, and/or postpartum hospitalization. Black individuals had the highest rate of antepartum, intrapartum, and postpartum non-transfusion and total SMM followed by American Indian individuals. Asian individuals had the lowest rate of non-transfusion and total SMM during antepartum and postpartum hospitalizations while White individuals had the lowest rate of non-transfusion and total SMM during the intrapartum hospitalization. Black individuals were 1.9 times more likely to experience non-transfusion SMM during the intrapartum hospitalization than White individuals, which increased to 2.8 times during the antepartum period and to 2.5 times during the postpartum period. Asian and Hispanic individuals were less likely to experience SMM in the postpartum period than White individuals. Including antepartum and postpartum hospitalizations resulted in disproportionately more cases among Black and American Indian individuals than among White, Hispanic, and Asian individuals. The additional cases were also more likely to occur among individuals with lower educational levels and individuals on government insurance.

CONCLUSION

Racial disparities in SMM are underreported in estimates that focus on the intrapartum hospitalization. Additionally, individuals with low socio-economic status bear the greatest burden of SMM occurring during the antepartum and postpartum periods. Approaches that focus on mitigating SMM during the intrapartum period only do not address the full spectrum of health disparities. El resumen está disponible en Español al final del artículo.

Ethics of Predicting and Preventing Preterm Birth

Preterm birth (PTB) occurs disproportionately among women who are minoritized and who live and work in poverty. This disadvantage occurs as a result of societal norms and policies that affect how people are treated and determine their access to a broad range of resources. Research that takes social context into account offers the best opportunity for identifying approaches to prevent PTB. The experience and knowledge of women from groups experiencing high rates of PTB can provide important insights for research design and for determining the feasibility and acceptability of potential interventions.

Beyond Birth Work: Addressing Social Determinants of Health With Community Perinatal Support Doulas

Adverse maternal and infant health outcomes among African Americans are increasingly recognized as indicators of a critical public health crisis in the United States. Research has found that stress is related to structural racism and the social determinants of health (SDOH) that cause avoidable, unfair inequities in resources, education, power, and opportunities across ethnic groups. This paper describes the SDOH needs and experiences of pregnant Black women from the perspective of doulas and Birthing Beautiful Communities (BBC) clients. The design was a qualitative description, using data collected over time (2017-2018, 2020-2021, and 2023). This study took place in Cleveland and Akron, Ohio and the sample included 58 clients, 26 doulas, and 2 resource intake specialist assistants (RISAs). Qualitative data included individual client interviews, three doula focus groups, and one interview with two BBC RISAs. Three coders used content analysis to deductively identify SDOHs and calculate the number of interviews that contained information about specific SDOHs. Although the sample reported issues with all SDOH, particular ones caused a cascade of SDOH effects. Transportation issues, for example, impeded women from being able to make it to work, doctor's appointments, and to purchase essential baby items (e.g., food, infant supplies). An inability to work-whether because of transportation challenges or pregnancy-related health complications-led to unstable housing and an inability to deal with transportation challenges. Many clients mentioned that housing was a major issue, with many clients experiencing housing instability. Implications include ensuring SDOH information is collected from a trusted source who can advocate and ensure access to a wide range of local resources, ensuring policies protect pregnant women from experiencing a cascade of SDOH that may contribute to continuing health disparate infant and maternal health outcomes in African American women.

Evaluating the Prevalence of Maternal Health Indicators on Infant Mortality Rates in Florida

Background The infant mortality rate is defined as the number of infant deaths for every 1000 live births. In 2020, the infant mortality rate was 5.8% in the state of Florida, compared to 7.0% in 2000. Although infant mortality rates have declined in the state of Florida, disparities influencing these rates exist across varying Florida counties, with the widest differences being compared between the healthiest versus unhealthiest counties in Florida. Many factors can contribute to high infant mortality rates in certain counties, including income inequality, access to and quality of healthcare, race/ethnicity, obesity, and disadvantaged socioeconomic status (SES). Methods This study utilized data from Florida Health Charts on infant mortality rates in the state of Florida and the Pregnancy and Young Child Profiles in 10 counties to examine how certain risk factors impact infant mortality outcomes in the state of Florida. These 10 counties consist of five healthiest and five unhealthiest counties, as determined by the 2022 County Health Rankings data. T-tests were used to evaluate the relationship between county health status and several county health indicators. Results The average infant mortality rate from 2011 to 2020 differed significantly among healthy and unhealthy counties (p-value=0.0000). Median household income, individuals below the poverty level, and those aged zero to 17 years old were found to differ significantly by county health status (p-values 0.0000, 0.001, and 0.009, respectively). However, mothers having no high school education, births with first-trimester care, births with adequate care, and births with late or no prenatal care were not statistically significant. Conclusion Our study suggests that counties more likely to have fewer resources than other counties, such as those considered unhealthy, are more impacted by a higher infant mortality rate. The unhealthy counties in this study were found to have lower average median household income, higher rates of no high school education among mothers, and less prenatal care in comparison to healthy counties.

Association of socioeconomic disadvantage and ethnicity with perinatal neonatal, and infant mortality in Slovakia

BACKGROUND

Infant mortality rates are reliable indices of the child and general population health status and health care delivery. The most critical factors affecting infant mortality are socioeconomic status and ethnicity. The aim of this study was to assess the association between socioeconomic disadvantage, ethnicity, and perinatal, neonatal, and infant mortality in Slovakia before and during the COVID-19 pandemic.

METHODS

The associations between socioeconomic disadvantage (educational level, long-term unemployment rate), ethnicity (the proportion of the Roma population) and mortality (perinatal, neonatal, and infant) in the period 2017-2022 were explored, using linear regression models.

RESULTS

The higher proportion of people with only elementary education and long-term unemployed, as well as the higher proportion of the Roma population, increases mortality rates. The proportion of the Roma population had the most significant impact on mortality in the selected period between 2017 and 2022, especially during the COVID-19 pandemic (2020-2022).

CONCLUSIONS

Life in segregated Roma settlements is connected with the accumulation of socioeconomic disadvantage. Persistent inequities between Roma and the majority population in Slovakia exposed by mortality rates in children point to the vulnerabilities and exposures which should be adequately addressed by health and social policies.

The association of maternal country/region of origin and nativity with infant mortality rate among Hispanic preterm infants

OBJECTIVES

Among US-born preterm infants of Hispanic mothers, we analyzed the unadjusted and adjusted infant mortality rate (IMR) by country/region of origin and maternal nativity status.

STUDY DESIGN

Using linked national US birth and death certificate data (2005-2014), we examined preterm infants of Hispanic mothers by subgroup and nativity. Clinical and sociodemographic covariates were included and the main outcome was death in the first year of life.

RESULTS

In our cohort of 891,216 preterm Hispanic infants, we demonstrated different rates of infant mortality by country and region of origin, but no difference between infants of Hispanic mothers who were US vs. foreign-born.

CONCLUSION

These findings highlight the need to disaggregate the heterogenous Hispanic birthing population into regional and national origin groups to better understand unique factors associated with adverse perinatal outcomes in order to develop more targeted interventions for these subgroups.

The Effects of Race, Ethnicity, and Maternal Education on Infant Mortality

BACKGROUND

The state of New Jersey has a large Black/African American (AA) versus White racial disparity in infant mortality and educational level at childbirth. This disparity, measured by rate ratio, increases with greater maternal education among varied racial-ethnic groups. The nature of this disparity measured by rate differences has not been explored.

OBJECTIVES

Infant birth and mortality data were used to examine whether racial or ethnic disparities in infant mortality increased with greater maternal education, comparing rate differences and rate ratios. Racial and ethnic variations in the association between maternal education and infant mortality were examined.

METHODS

Data were from the New Jersey State Health Assessment Data for all New Jersey births between 2014 and 2018 stratified by race and ethnicity, maternal education, and infant mortality ( n = 481,333). R software was used to create a data set and estimate additive and multiplicative interactions, rate differences, and rate ratios for infant mortality by maternal race/ethnicity and educational levels among four racial-ethnic groups.

RESULTS

Infant mortality was significantly greater for Black/AA and Hispanic mothers than for White mothers. At all educational levels, Black/AA mothers had the highest prevalence of infant mortality compared to other racial or ethnic groups. Rate differences in infant mortality showed a decrease in Black/AA-White differences for mothers with a high school education or less compared to mothers with a college degree. However, rate ratios showed an increase in Black/AA-White ratio with increasing education levels for mothers with high school education or less than mothers with a college degree. Risk ratios comparing infant mortality for Black/AA versus Hispanic or Asian mothers showed more than a twofold greater risk at all education levels for Black/AA infants. Finally, college-educated Black/AA mothers had significantly higher rates of infant mortality than White or Hispanic mothers with a high school education or less.

DISCUSSION/IMPLICATIONS

Black/AA mothers with a college degree had a higher infant mortality rate than White, Hispanic, or Asian mothers with a high school education or less. Future research should address contextual/systemic contributors to this disparity.

Racial and Ethnic Disparities in Delivery In-Hospital Mortality or Maternal End-Organ Injury: A Multistate Analysis, 2007-2020

Background: In the United States, Black maternal mortality is 2-4 × higher than that of White maternal mortality, with differences also present in severe maternal morbidity and other measures. However, limited research has comprehensively studied multilevel social determinants of health, and their confounding and effect modification on obstetrical outcomes. Materials and Methods: We performed a retrospective multistate analysis of adult inpatient delivery hospitalizations (Florida, Kentucky, Maryland, New Jersey, New York, North Carolina, and Washington) between 2007 and 2020. Multilevel multivariable models were used to test the confounder-adjusted association for race/ethnicity and the binary outcomes (1) in-hospital mortality or maternal end-organ injury and (2) in-hospital mortality only. Stratified analyses were performed to test effect modification. Results: The confounder-adjusted odds ratio showed that Black (1.33, 95% confidence interval [CI]: 1.30-1.36) and Hispanic (1.14, 95% CI: 1.11-1.18) as compared with White patients were more likely to die in-hospital or experience maternal end-organ injury. For Black and Hispanic patients, stratified analysis showed that findings remained significant in almost all homogeneous strata. After statistical adjustment, Black as compared with White patients were more likely to die in-hospital (1.49, 95% CI: 1.21-1.82). Conclusions: Black and Hispanic patients had higher adjusted odds of in-patient mortality and end-organ damage after birth than White patients. Race and ethnicity serve as strong predictors of health care inequality, and differences in outcomes may reflect broader structural racism and individual implicit bias. Proposed solutions require immense and multifaceted active efforts to restructure how obstetrical care is provided on the societal, hospital, and patient level.

Determinants of Neonatal Mortality in the United States

Introduction Despite a notable reduction in infant mortality over recent decades, the United States, with a rate of 5.8 deaths per 1,000 live births, still ranks unfavorably compared to other developed countries. This improvement appears inadequate when contrasted with the country's healthcare spending, the highest among developed nations. A significant proportion of this infant mortality rate can be attributed to neonatal fatalities. Objective The present study aimed to determine the risk factors associated with neonatal deaths in the United States. Method Using the United States Vital Statistics records, we conducted a retrospective study on childbirths between 2015 and 2019 to identify risk factors for neonatal mortality. Our final multivariate analysis included maternal parameters like age, insurance type, education level, cesarean section rate, pregnancy inductions and augmentations, weight gain during pregnancy, birth weight, number of prenatal visits, pre-existing conditions like chronic hypertension and prediabetes, and pregnancy complications like gestational diabetes mellitus (GDM). These variables were incorporated to enhance our model's sensitivity and specificity. Result There were 51,174 neonatal mortalities. Mothers with augmentation of labor had a 25% reduction in neonatal mortalities (NM) (OR=0.75; 95% CI 0.72-0.79), while labor induction was associated with a 31% reduction in NM (OR=0.69; 95% CI 0.66-0.72). Women above 40 years had a 29% increase in NM rate (OR=1.29;95% CI 1.15-1.44). Women without prenatal care have a 22% increase in the risk of NM (OR=1.22; 95% CI 1.14-1.30). The present model has a 60.7% sensitivity and a 99.9% specificity. Conclusion In the present study, significant interventions such as labor induction, augmentation, and prenatal care were associated with improved neonatal outcomes. These findings could serve as an algorithm for improving neonatal outcomes in the United States.

Early-Life Outcomes in Relation to Social Determinants of Health for Children Born Extremely Preterm

OBJECTIVE

To characterize the relationships between social determinants of health (SDOH) and outcomes for children born extremely preterm.

STUDY DESIGN

This is a cohort study of infants born at 22-26 weeks of gestation in National Institute of Child Health and Human Development Neonatal Research Network centers (2006-2017) who survived to discharge. Infants were classified by 3 maternal SDOH: education, insurance, and race. Outcomes included postmenstrual age (PMA) at discharge, readmission, neurodevelopmental impairment (NDI), and death postdischarge. Regression analyses adjusted for center, perinatal characteristics, neonatal morbidity, ethnicity, and 2 SDOH (eg, group comparisons by education adjusted for insurance and race).

RESULTS

Of 7438 children, 5442 (73%) had at least 1 risk-associated SDOH. PMA at discharge was older (adjusted mean difference 0.37 weeks, 95% CL 0.06, 0.68) and readmission more likely (aOR 1.27, 95% CL 1.12, 1.43) for infants whose mothers had public/no insurance vs private. Neither PMA at discharge nor readmission varied by education or race. NDI was twice as likely (aOR 2.36, 95% CL 1.86, 3.00) and death 5 times as likely (aOR 5.22, 95% CL 2.54, 10.73) for infants with 3 risk-associated SDOH compared with those with none.

CONCLUSIONS

Children born to mothers with public/no insurance were older at discharge and more likely to be readmitted than those born to privately insured mothers. NDI and death postdischarge were more common among children exposed to multiple risk-associated SDOH at birth compared with those not exposed. Addressing disparities due to maternal education, insurance coverage, and systemic racism are potential intervention targets to improve outcomes for children born preterm.

Association between infant mortality and parental educational level: An analysis of data from Vital Statistics and Census in Japan

This study investigated the association between parental educational level and infant mortality using data from Vital Statistics and Census in Japan. We used the Census data in 2020 and birth and mortality data from the Vital Statistics from 2018 to 2021 in Japan. Data linkage was conducted between birth data and the Census to link the educational level with parents for birth data and between the birth data and mortality data to identify births that resulted in infant mortality. Four educational levels were compared: "junior high school," "high school," "technical school or junior college," and "university." A multivariate logistic regression model was used to investigate an association between parental educational level and infant mortality using other risk factors as covariates. After the data linkage, data on 890,682 births were analyzed. The proportion of junior high school or high school graduates was higher among fathers and mothers for births with infant mortality compared with that among those for births without infant mortality; in contrast, the proportion of university graduates was lower for births with infant mortality than those without infant mortality. Regression analysis showed that mothers with junior high school or high school graduates were significantly and positively associated with infant mortality compared with those with university graduates. As a conclusion, lower educational level in mothers was positively associated with infant mortality, and it was shown that a difference in infant mortality depending on parental educational level existed in Japan.

Examining sources of post-acute care inequities with layered target matching

OBJECTIVE

To examine factors associated with racial inequities in discharge location, skilled nursing facility (SNF) utilization, and readmissions.

DATA SOURCES

A 20% sample of longitudinal Medicare claims from 2016 to 2018.

STUDY DESIGN

We present layered target matching, a method for studying sources of inequities. Layered target matching examines a fixed target population profile representing any race, ethnicity, or vulnerable population, sequentially adjusting for sets of characteristics that may contribute to inequities these groups endure. We use the method to study racial inequities in post-acute care use and readmissions.

DATA COLLECTION/EXTRACTION METHODS

We studied Black and non-Hispanic White fee-for-service Medicare beneficiaries aged 66+ admitted to short-term acute-care hospitals for qualifying diagnoses or procedures between January 1, 2016 and November 30, 2018.

PRINCIPAL FINDINGS

Admitted Black patients tended to be younger, had significantly higher rates of risk factors such as diabetes, stroke, or renal disease, and were much more frequently admitted to large or academic hospitals. Relative to demographically similar White patients, Black patients were significantly more likely to be discharged to SNFs (21.8% vs. 19.3%, difference = 2.5%, p < 0.0001) and to receive any SNF care within 30 days of discharge (25.3% vs. 22.4%, difference = 2.9%, p < 0.0001). Black patients were also significantly more likely to experience 30-day readmission (18.7% vs. 14.5%, difference = 4.2%, p < 0.0001). Differences in reasons for hospitalization and risk factors explained most of the differences in discharge location, post-acute care use, and readmission rates, while additional adjustment for differences in hospital characteristics and complications made little difference for any of the measures studied.

CONCLUSIONS

We found significant Black-White differences in discharge to SNFs, SNF utilization, and readmission rates. Using layered target matching, we found that differences in risk factors and reasons for hospitalization explained most of these differences, while differences in hospitals did not materially impact the differences.

Racial/ethnic disparities in severe maternal morbidity: An intersectional lifecourse approach

Despite long-existing calls to address alarming racial/ethnic gaps in severe maternal morbidity (SMM), research that considers the impact of intersecting social inequities on SMM risk remains scarce. Invoking intersectionality theory, we sought to assess SMM risk at the nexus of racial/ethnic marginalization, weathering, and neighborhood/individual socioeconomic disadvantage. We used birth hospitalization records from California across 20 years (1997-2017, N = 9,806,406) on all live births ≥20 weeks gestation. We estimated adjusted average predicted probabilities of SMM at the combination of levels of race/ethnicity, age, and neighborhood deprivation or individual socioeconomic status (SES). The highest risk of SMM was observed among Black birthing people aged ≥35 years who either resided in the most deprived neighborhoods or had the lowest SES. Black birthing people conceptualized to be better off due to their social standing (aged 20-34 years and living in the least deprived neighborhoods or college graduates) had comparable and at times worse risk than White birthing people conceptualized to be worse off (aged ≥35 years and living in the most deprived neighborhoods or had a high-school degree or less). Our findings highlight the need to explicitly address structural racism as the driver of racial/ethnic health inequities and the imperative to incorporate intersectional approaches.

Refreshing the Perinatal Periods of Risk: A New Reference Group and Nationwide Large-County-Level Analyses

INTRODUCTION

The Perinatal Periods of Risk approach (PPOR) is designed for use by communities to assess and address the causes of high fetal-infant mortality rates using vital records data. The approach is widely used by local health departments and their community and academic partners to inform and motivate systems changes. PPOR was developed and tested in communities based on data years from 1995 to 2002. Unfortunately, a national reference group has not been published since then, primarily due to fetal death data quality limitations.

METHODS

This paper assesses data quality and creates a set of unbiased national reference groups using 2014-2016 national vital records data. Phase 1 and Phase 2 analytic methods were used to divide excess mortality into six components and create percentile plots to summarize the distribution of 100 large US counties for each component.

RESULTS

Eight states with poor fetal death data quality were omitted from the reference groups to reduce bias due to missing maternal demographic information. There are large Black-White disparities among reference groups with the same age and education restrictions, and these vary by component. PPOR results vary by region, maternal demographics, and county. The magnitude of excess mortality components varies widely across US counties.

DISCUSSION

New national reference groups will allow more communities to do PPOR. Percentile plots of 100 large US counties provide an additional benchmark for new communities using PPOR and help emphasize problem areas and potential solutions.

Geographic heterogeneity in Black-white infant mortality disparities

Despite recent decreases in Black infant mortality, racial disparities persist, motivating continued research into factors related to these inequalities. While the inverse association between education and infant mortality has been documented across races, less is known about its geographic heterogeneity. Using vital statistics from the National Center for Health Statistics, this study considers Black-white disparities in infant mortality for births occurring between 2011 and 2015 across regions and metropolitan status of maternal residence. With logistic regressions, we investigate heterogeneity in maternal educational gradients of infant mortality by geographic residence both within and between races. Beyond confirming the well-known relationship between education and infant mortality, our findings document a slight metropolitan advantage for infants born to white mothers as well as lower returns to education for infants born to Black mothers residing in nonmetropolitan counties. We observe a metropolitan advantage for infants born to Black mothers with at least a bachelor's degree, but a metropolitan disadvantage for infants born to Black mothers with less than a high school degree. The South is driving this divergence, pointing to particular mechanisms limiting returns to education for Southern Black mothers in nonmetropolitan areas. This paper's geographic perspective emphasizes that racial infant health disparities are not uniform across the country and cannot be fully understood through individual and household characteristics.

Sociodemographic Disparities in the Diagnostic Management of Pediatric Thyroid Nodules

Importance

Thyroid cancer is the most common pediatric endocrine malignant neoplasm. Disparities in the workup of thyroid nodules may be significantly associated with thyroid cancer outcomes.

Objective

To determine the association of sociodemographic factors with the odds of receiving a biopsy, timeliness of the procedure, and risk of nodule malignancy.

Design, Setting, and Participants

This was a retrospective cross-sectional study using insurance claims data from the Optum Clinformatics Data Mart database. The study cohort comprised pediatric patients diagnosed with single thyroid nodules between 2003 and 2020. Data analysis was performed from January 1, 2003, to June 30, 2020.

Main Outcomes and Measures

Multivariable logistic regression models were used to identify demographic variables associated with biopsy and nodule malignant neoplasm. A multivariable linear regression model was used to assess the time between thyroid nodule diagnosis and biopsy.

Results

Of 11 643 children (median [IQR] age at diagnosis or procedure, 15 [12-17] years; 8549 [73.2%] were female and 3126 [26.8%] were male) diagnosed with single thyroid nodules, 2117 (18.2%) received a biopsy. Among the patients who received a biopsy, 304 (14.4%) were found to have a malignant nodule. Greater parental education was associated with a shorter diagnosis-to-biopsy interval (mean difference, -7.24 days; 95% CI, -13.75 to -0.73). Older age at nodule diagnosis (odds ratio [OR], 1.11; 95% CI, 1.09-1.13) and female gender (OR, 1.25; 95% CI, 1.11-1.40) were associated with increased odds of receiving a biopsy, while Black/African American (OR, 0.80; 95% CI, 0.65-0.99) and Hispanic (OR, 0.84; 95% CI, 0.72-0.99) patients had lower odds of receiving a biopsy compared with White patients. Finally, female gender (OR, 1.08; 95% CI, 0.80-1.47) was not associated with lower odds of nodule malignant neoplasm.

Conclusions and Relevance

Findings of this cross-sectional study highlight disparities in the diagnostic management of pediatric thyroid nodules. These results call for future work to ensure equitable access to thyroid care for all children.

Meeting the Moment: Bioethics in the Time of Black Lives Matter

In this article, I begin by describing what I call this Black Lives Matter moment in the US. I then offer three reasons for considering racism as a bioethical issue, the least discussed of which is the way in which racism acts as a barrier to the creation of better healthcare systems. Next, I argue that the concept of race itself constitutes a bioethical issue in a way that is not fully reducible to racism. Finally, I discuss how we, both bioethicists and health care professionals, might meet this moment by identifying individual points of responsibility (beyond liability) for structural injustice.

Inequities in Adverse Maternal and Perinatal Outcomes: The Effect of Maternal Race and Nativity

OBJECTIVES

To evaluate the effect of race and ethnicity on differences in maternal and perinatal outcomes among U.S.-born and foreign-born women, as well as racial and ethnic disparities in outcomes within these groups.

METHODS

This retrospective study analyzed singleton pregnancies (n = 11,518) among women delivering at Boston Medical Center from January 2010-March 2015. Outcomes of interest included preterm birth, early preterm birth, cesarean delivery, hypertensive disorders, diabetes, low birth weight at term (LBW, < 2500 g), NICU admission and intrauterine fetal demise (IUFD). Prevalence ratios and 95% confidence intervals comparing outcomes between U.S.- and foreign-born women were calculated and stratified by race. Obstetric outcomes among Black and Hispanic women were compared to those of white women within both U.S.- and foreign-born groups.

RESULTS

Preterm birth, hypertensive disorders, LBW and NICU admission were more likely to occur among U.S.-born women and their neonates compared to foreign-born women. Controlling for sociodemographic characteristics did not significantly impact these disparities. Among foreign-born women, Black women had a higher prevalence of many maternal and neonatal complications, while Hispanic women had a lower prevalence of some complications compared to white women. Black woman and infants consistently exhibit worse outcomes regardless of their nativity, while Hispanic women foreign-born women experience less disparate outcomes.

CONCLUSIONS FOR PRACTICE

Overall, women born in the United States are at higher risk of several adverse perinatal outcomes compared to foreign-born women. Racial and ethnic disparities in birth outcomes exist in both groups. However, the complex interplay between biopsychosocial influences that mediate these inequities appear to have different effects among U.S- and foreign- born women. A better understanding of these factors can be used to combat disparities and improve outcomes for all women.