Neonatal outcomes after preterm birth by mothers' health insurance status at birth: a retrospective cohort study

Interaction of Maternal Race/Ethnicity, Insurance, and Education Level on Pregnancy Outcomes: A Retrospective Analysis of the United States Vital Statistics Records

OBJECTIVE

The objective is to determine the association between maternal race/ethnicity, insurance, education level, and pregnancy outcomes.

METHODS

We queried the U.S. vital statistics records from 2015 to 2019 to analyze all deliveries. Using a multivariate analysis model, we determined the interaction between maternal race, insurance, education, and pregnancy outcomes. The outcome measures were the 5-min Apgar score, neonatal unit admission, neonates receiving assisted ventilation > 6 hours, mothers requiring blood transfusion, and the intensive care unit admission.

RESULT

There were 13,213,732 deliveries that met our inclusion criteria. In the study population, 52.7% were white, 14.1% blacks, 22.9% Hispanics, and 10.4% belonged to other races. 37.5% of the women had a high school education, 49.1% had a college education, and 12.3% had advanced degrees. Black mothers with high school education were more likely to require blood transfusion following delivery than Whites at the same education level, OR=1.08 (95% CI 1.05-1.11, p < 0.05). They were also more likely to be admitted into intensive care. The difference only disappeared among blacks with advanced education (OR=1.0; 95% CI 0.89-1.12, p > 0.05). Across all races/ethnicities, private insurance and advanced education were associated with better pregnancy outcomes.

CONCLUSION

In the U.S., women with high socioeconomic status have better pregnancy outcomes across all races/ethnicities.

Does maternal race or ethnicity modify the association between maternal psychiatric disorders and preterm birth?

PURPOSE

Preterm birth risk has been linked to maternal racial and ethnic background, particularly African American heritage; however, the association of maternal race and ethnicity with psychiatric disorders and preterm birth has received relatively limited attention.

METHODS

The Consortium on Safe Labor (2002-2008) is a nationwide U.S. cohort study with 223,394 singleton pregnancies. Clinical data were obtained from electronic medical records, including maternal diagnoses of psychiatric disorders. Relative risk (RR) and 95% confidence intervals (CI) were estimated for the association between maternal psychiatric disorders and preterm birth (<37 completed weeks) using log-binomial regression with generalized estimating equations. The interaction effect of maternal psychiatric disorders with race and ethnicity was also evaluated.

RESULTS

Non-Hispanic White (RR, 1.42; 95% CI, 1.35-1.49), Hispanic (RR, 1.44; 95% CI, 1.29-1.60), and non-Hispanic Black (RR, 1.21, 95% CI, 1.13-1.29) women with any psychiatric disorder were at increased risk for delivering preterm infants, compared with women without any psychiatric disorder. However, non-Hispanic Black women with any psychiatric disorder, depression, bipolar disorder, and schizophrenia had a significantly lower increase in preterm birth risk than non-Hispanic White women.

CONCLUSIONS

Despite the significant association between maternal psychiatric disorders and preterm birth risk, psychiatric disorders did not appear to contribute to racial and ethnic disparities in preterm birth.

Association between insurance type and pregnancy outcomes in women diagnosed with hypertensive disorders of pregnancy

Objective: Hypertension in pregnancy is associated with adverse maternal and neonatal outcomes. Previous studies have demonstrated disparities in the risk of preeclampsia based on race, educational attainment, census tract income level and household income. Yet, data on the association of insurance type, classification of hypertension in pregnancy and outcomes have not been well described. We sought to compare outcomes in women with hypertensive disorders of pregnancy, by private versus public insurance.Study design: This was a retrospective cohort study of subjects with a hypertensive disorder of pregnancy that delivered ≥23-week gestation at Oregon Health & Science University (October 2013-December 2017). The cohort began with the 2013 American College of Obstetricians and Gynecologists Executive Summary on Hypertension in Pregnancy, which advised surveillance for severe features of disease in women with hypertension. Utilizing ICD-9 and ICD-10 discharge codes, followed by individual chart review, subjects were stratified into two groups by insurance status: Medicaid (public insurance), or individual or group health insurance (private insurance). As primary outcomes, we assessed severe features of preeclampsia, adverse maternal or neonatal outcomes (composite), and final hypertensive diagnosis: (i) chronic hypertension; (ii) gestational hypertension; (iii) preeclampsia without severe features and, (iv) preeclampsia with severe features. Differences in demographic and outcome data were analyzed by chi-square, t-test, and logistic regression.Results: Among 10 132 deliveries, 1335 (13.2%) were delivered with a hypertensive disorder of pregnancy. Medicaid covered 54.1% (722) of these deliveries; 44.1% (589) were covered by private insurance, and 1.8% (24) had unknown insurance. There was a similar percentage of subjects with Medicaid or private insurance in each hypertensive group (p = .08). However, compared to subjects with private insurance, those with Medicaid had more severe blood pressure (BP) elevations (systolic BP ≥160 mmHg, p = .001) and more cases of eclampsia (p = .04), while neonates of subjects with Medicaid had more intensive care unit admissions (p = .02), and preterm births (p < .001). The association between Medicaid insurance and severe BP elevation, or adverse neonatal outcomes, persisted after multivariable adjustment.Conclusion: Medicaid was not associated with a particular hypertensive disorder in pregnancy, yet those with Medicaid experienced more severe BP elevations and higher rates of adverse neonatal outcomes. More research is needed to understand potential risk factors and ways to improve outcomes for those with publicly funded insurance.

Comparison between public and private sectors of care and disparities in adverse neonatal outcomes following emergency intrapartum cesarean at term - A retrospective cohort study

BACKGROUND

Perinatal outcomes may be influenced by a variety of factors including maternal demographics and medical condition as well as socio-economic status. The evidence for disparities in health outcomes stratified by type of care (public or private) is lacking. The aim of this study was to investigate short term neonatal outcomes following category 1 and 2 emergency cesareans at term between publicly and privately funded women at a single major tertiary centre in Australia. Category 1-immediate threat to life (maternal or fetal); Category 2-maternal or fetal compromise that is not immediately life-threatening.

METHODS

This was a retrospective, cross sectional study of 61355 term singleton babies born at the Mater Mother's Hospital in Brisbane, Australia in 2007-2014. We collected data from the hospital's maternity database and compared maternal demographics, indications for cesarean and neonatal outcomes for publicly and privately funded women.

RESULTS

Over the study period there were 32477 public and 28878 private, term singleton births. Compared to the publicly funded cohort, privately insured women were older, had lower BMI, were of Caucasian ethnicity, Australian born, nulliparous, had shorter labors and had lower rates of hypertensive disorders and diabetes. The most common indications for category 1 and category 2 cesareans in combination were non-reassuring fetal status followed by failure to progress in labor and malpresentation. For both category 1 and 2 cesareans, neonatal outcomes (Apgar score <7 at 5 minutes, abnormal cord gases, Neonatal Critical Care Unit admission rates, rates of severe respiratory distress and jaundice) were significantly worse in the publicly funded compared to the privately insured cohort Multivariate analyses controlling for maternal age, ethnicity, country of birth, parity, hypertension, diabetes mellitus, gestational age at birth and length of labour confirmed that private insurance status was highly protective for the perinatal outcomes of Apgar score <7 at 5 minutes (aOR 0.26, 95% CI 0.13-0.55), admission to NCCU (OR 0.51, 95% CI 0.30-0.92) and respiratory distress (aOR 0.60, 95% CI 0.41-0.86).

CONCLUSION

Birth in the private health sector was inversely associated with adverse neonatal outcomes following category 1 and 2 cesareans.