Racial and Ethnic Disparities in Adverse Perinatal Outcomes at Term

Jacqueline G. Parchem; Madeline Murguia Rice; William A. Grobman; Jennifer L. Bailit; Ronald J. Wapner; Michelle P. Debbink; John M. Thorp Jr; Steve N. Caritis; Mona Prasad; Alan T.N. Tita; George R. Saade; Yoram Sorokin; Dwight J. Rouse; Jorge E. Tolosa; for the Eunice Kennedy Shriver National Institute of Child Health Human Development Maternal-Fetal Medicine Units (MFMU) Network

doi:10.1055/s-0041-1730348

American Journal of Perinatology, Table of Contents

Am J Perinatol 2023; 40(05): 557-566
DOI: 10.1055/s-0041-1730348

Original Article

Racial and Ethnic Disparities in Adverse Perinatal Outcomes at Term

Authors

Jacqueline G. Parchem

¹Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, and Children's Memorial Hermann Hospital, Houston, Texas
Madeline Murguia Rice

²George Washington University Biostatistics Center, Washington, District of Columbia
William A. Grobman

³Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
Jennifer L. Bailit

⁴Department of Obstetrics and Gynecology, MetroHealth Medical Center-Case Western Reserve University, Cleveland, Ohio
Ronald J. Wapner

⁵Department of Obstetrics and Gynecology, Columbia University, New York, New York
Michelle P. Debbink

⁶Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, Utah
John M. Thorp Jr

⁷Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Steve N. Caritis

⁸Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania
Mona Prasad

⁹Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
Alan T.N. Tita

¹⁰Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
George R. Saade

¹¹Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
Yoram Sorokin

¹²Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan
Dwight J. Rouse

¹³Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island
Jorge E. Tolosa

¹⁴Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon

for the Eunice Kennedy Shriver National Institute of Child Health Human Development Maternal-Fetal Medicine Units (MFMU) Network

Abstract

Objective This study aimed to evaluate whether racial and ethnic disparities in adverse perinatal outcomes exist at term.

Study Design We performed a secondary analysis of a multicenter observational study of 115,502 pregnant patients and their neonates (2008–2011). Singleton, nonanomalous pregnancies delivered from 37 to 41 weeks were included. Race and ethnicity were abstracted from the medical record and categorized as non-Hispanic White (White; referent), non-Hispanic Black (Black), non-Hispanic Asian (Asian), or Hispanic. The primary outcome was an adverse perinatal composite defined as perinatal death, Apgar score < 4 at 5 minutes, ventilator support, hypoxic–ischemic encephalopathy, subgaleal hemorrhage, skeletal fracture, infant stay greater than maternal stay (by ≥ 3 days), brachial plexus palsy, or facial nerve palsy.

Results Of the 72,117 patients included, 48% were White, 20% Black, 5% Asian, and 26% Hispanic. The unadjusted risk of the primary outcome was highest for neonates of Black patients (3.1%, unadjusted relative risk [uRR] = 1.16, 95% confidence interval [CI]: 1.04–1.30), lowest for neonates of Hispanic patients (2.1%, uRR = 0.80, 95% CI: 0.71–0.89), and no different for neonates of Asian (2.6%), compared with those of White patients (2.7%). In the adjusted model including age, body mass index (BMI), smoking, obstetric history, and high-risk pregnancy, differences in risk for the primary outcome were no longer observed for neonates of Black (adjusted relative risk [aRR] = 1.06, 95% CI: 0.94–1.19) and Hispanic (aRR = 0.92, 95% CI: 0.81–1.04) patients. Adding insurance to the model lowered the risk for both groups (aRR = 0.85, 95% CI: 0.75–0.96 for Black; aRR = 0.68, 95% CI: 0.59–0.78 for Hispanic).

Conclusion Although neonates of Black patients have the highest frequency of adverse perinatal outcomes at term, after adjustment for sociodemographic factors, this higher risk is no longer observed, suggesting the importance of developing strategies that address social determinants of health to lessen extant health disparities.

Key Points

Term neonates of Black patients have the highest crude frequency of adverse perinatal outcomes.
After adjustment for confounders, higher risk for neonates of Black patients is no longer observed.
Disparities in outcomes are strongly related to insurance status.

Keywords

disparities - neonatal outcome - perinatal outcome - race and ethnicity - term

Full Text

References

References
1 Center for Disease Control and Prevention. Health equity. Accessed October 8, 2020 at: https://www.cdc.gov/chronicdisease/healthequity/index.htm
2 Center for Disease Control and Prevention. Social determinants of health: know what affects health. Accessed October 8, 2020 at: https://www.cdc.gov/socialdeterminants/index.htm
3 Committee on Health Care for Underserved Women. ACOG committee opinion no. 649: racial and ethnic disparities in obstetrics and gynecology. Obstet Gynecol 2015; 126 (06) e130-e134
4 Debbink MP, Bader MDM. Racial residential segregation and low birth weight in Michigan's metropolitan areas. Am J Public Health 2011; 101 (09) 1714-1720
5 Howell EA, Egorova N, Balbierz A, Zeitlin J, Hebert PL. Black-white differences in severe maternal morbidity and site of care. Am J Obstet Gynecol 2016; 214 (01) 122.e1-122.e7
6 Osypuk TL, Slaughter-Acey JC, Kehm RD, Misra DP. Life-course social mobility and reduced risk of adverse birth outcomes. Am J Prev Med 2016; 51 (06) 975-982
7 Wallace M, Crear-Perry J, Richardson L, Tarver M, Theall K. Separate and unequal: Structural racism and infant mortality in the US. Health Place 2017; 45: 140-144
8 Chambers BD, Arabia SE, Arega HA. et al. Exposures to structural racism and racial discrimination among pregnant and early post-partum Black women living in Oakland, California. Stress Health 2020; 36 (02) 213-219
9 Jain JA, Temming LA, D'Alton ME. et al. SMFM special report: putting the “M” back in MFM: reducing racial and ethnic disparities in maternal morbidity and mortality: a call to action. Am J Obstet Gynecol 2018; 218 (02) B9-B17
10 Howell EA, Brown H, Brumley J. et al. Reduction of peripartum racial and ethnic disparities: a conceptual framework and maternal safety consensus bundle. Obstet Gynecol 2018; 131 (05) 770-782
11 Admon LK, Winkelman TNA, Zivin K, Terplan M, Mhyre JM, Dalton VK. Racial and ethnic disparities in the incidence of severe maternal morbidity in the United States, 2012-2015. Obstet Gynecol 2018; 132 (05) 1158-1166
12 Petersen EE, Davis NL, Goodman D. et al. Racial/ethnic disparities in pregnancy-related deaths - United States, 2007-2016. MMWR Morb Mortal Wkly Rep 2019; 68 (35) 762-765
13 Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-related mortality in the United States, 2011-2013. Obstet Gynecol 2017; 130 (02) 366-373
14 Parchem JG, Gupta M, Chen H-Y, Wagner S, Mendez-Figueroa H, Chauhan SP. Adverse infant and maternal outcomes among low-risk term pregnancies stratified by race and ethnicity. Obstet Gynecol 2020; 135 (04) 925-934
15 Loftin R, Chen A, Evans A, DeFranco E. Racial differences in gestational age-specific neonatal morbidity: further evidence for different gestational lengths. Am J Obstet Gynecol 2012; 206 (03) 259.e1-259.e6
16 Shapiro-Mendoza CK, Tomashek KM, Kotelchuck M, Barfield W, Weiss J, Evans S. Risk factors for neonatal morbidity and mortality among “healthy,” late preterm newborns. Semin Perinatol 2006; 30 (02) 54-60
17 Berman S, Richardson DK, Cohen AP, Pursley DM, Lieberman E. Relationship of race and severity of neonatal illness. Am J Obstet Gynecol 2001; 184 (04) 668-672
18 Bailit JL, Grobman WA, Rice MM. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network. Risk-adjusted models for adverse obstetric outcomes and variation in risk-adjusted outcomes across hospitals. Am J Obstet Gynecol 2013; 209 (05) 446.e1-446.e30
19 Chauhan SP, Rice MM, Grobman WA. et al; MSCE, for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. Neonatal morbidity of small- and large-for-gestational-age neonates born at term in uncomplicated pregnancies. Obstet Gynecol 2017; 130 (03) 511-519
20 Alexander GR, Kogan MD, Himes JH. 1994-1996 U.S. singleton birth weight percentiles for gestational age by race, Hispanic origin, and gender. Matern Child Health J 1999; 3 (04) 225-231
21 Benjamini Y, Hochberg Y. Controlling the false discovery rate: A practical and powerful approach to multiple testing. J R Stat Soc B 1995; 57 (01) 289-300
22 American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics. ACOG practice bulletin no. 203: chronic hypertension in pregnancy. Obstet Gynecol 2019; 133 (01) e26-e50
23 American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 202: gestational hypertension and preeclampsia. Obstet Gynecol 2019; 133: e1-e25
24 American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics. ACOG practice bulletin no. 201: pregestational diabetes mellitus. Obstet Gynecol 2018; 132 (06) e228-e248
25 Ovesen P, Rasmussen S, Kesmodel U. Effect of prepregnancy maternal overweight and obesity on pregnancy outcome. Obstet Gynecol 2011; 118 (2, pt 1): 305-312
26 Butwick AJ, Blumenfeld YJ, Brookfield KF, Nelson LM, Weiniger CF. Racial and ethnic disparities in mode of anesthesia for cesarean delivery. Anesth Analg 2016; 122 (02) 472-479
27 Ong BY, Cohen MM, Palahniuk RJ. Anesthesia for cesarean section--effects on neonates. Anesth Analg 1989; 68 (03) 270-275
28 Alexander JM, McIntire DM, Leveno KJ. Chorioamnionitis and the prognosis for term infants. Obstet Gynecol 1999; 94 (02) 274-278
29 Rouse DJ, Landon M, Leveno KJ. et al; National Institute of Child Health And Human Development, Maternal-Fetal Medicine Units Network. The maternal-fetal medicine units cesarean registry: chorioamnionitis at term and its duration-relationship to outcomes. Am J Obstet Gynecol 2004; 191 (01) 211-216
30 Mendez-Figueroa H, Chauhan SP, Sangi-Haghpeykar H, Aagaard K. Pregnancy outcomes among Hispanics stratified by country of origin. Am J Perinatol 2021; 38 (05) 497506-497506
31 Brown HL, Chireau MV, Jallah Y, Howard D. The “Hispanic paradox”: an investigation of racial disparity in pregnancy outcomes at a tertiary care medical center. Am J Obstet Gynecol 2007; 197 (02) 197.e1-197.e7 , discussion 197.e7–197.e9
32 Louis JM, Menard MK, Gee RE. Racial and ethnic disparities in maternal morbidity and mortality. Obstet Gynecol 2015; 125 (03) 690-694
33 Shaw RJ, Pickett KE. The health benefits of Hispanic communities for non-Hispanic mothers and infants: another Hispanic paradox. Am J Public Health 2013; 103 (06) 1052-1057
34 Rosenstein MG, Snowden JM, Cheng YW, Caughey AB. The mortality risk of expectant management compared with delivery stratified by gestational age and race and ethnicity. Am J Obstet Gynecol 2014; 211 (06) 660.e1-660.e8
35 Chen H-Y, Chauhan SP, Rankins NC, Ananth CV, Siddiqui DS, Vintzileos AM. Racial and ethnic disparities in infant mortality in the United States: the role of gestational age. Am J Perinatol 2013; 30 (06) 469-475
36 Vilchez G, Chelliah A, Argoti P, Jeelani R, Bahado-Singh R. Maternal race and neonatal outcomes after elective repeat cesarean delivery. J Matern Fetal Neonatal Med 2014; 27 (04) 368-371
37 Janevic T, Zeitlin J, Auger N. et al. Association of race/ethnicity with very preterm neonatal morbidities. JAMA Pediatr 2018; 172 (11) 1061-1069
38 Howell EA, Janevic T, Hebert PL, Egorova NN, Balbierz A, Zeitlin J. Differences in morbidity and mortality rates in black, white, and hispanic very preterm infants among new york city hospitals. JAMA Pediatr 2018; 172 (03) 269-277
39 Anderson JG, Rogers EE, Baer RJ. et al. Racial and ethnic disparities in preterm infant mortality and severe morbidity: a population-based study. Neonatology 2018; 113 (01) 44-54
40 Yee LM, Costantine MM, Rice MM. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. Racial and ethnic differences in utilization of labor management strategies intended to reduce cesarean delivery rates. Obstet Gynecol 2017; 130 (06) 1285-1294
41 Simhan HN, Krohn MA. Paternal race and preterm birth. Am J Obstet Gynecol 2008; 198 (06) 644.e1-644.e6
42 Misra DP, Caldwell C, Young Jr. AA, Abelson S. Do fathers matter? Paternal contributions to birth outcomes and racial disparities. Am J Obstet Gynecol 2010; 202 (02) 99-100
43 Sigurdson K, Mitchell B, Liu J. et al. Racial/ethnic disparities in neonatal intensive care: A systematic review. Pediatrics 2019; 144 (02) e20183114
44 Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Race, ethnicity, and nativity differentials in pregnancy-related mortality in the United States: 1993-2006. Obstet Gynecol 2012; 120 (2, pt 1): 261-268
45 Singh GK, Yu SM. Adverse pregnancy outcomes: differences between US- and foreign-born women in major US racial and ethnic groups. Am J Public Health 1996; 86 (06) 837-843
46 Scott KA, Chambers BD, Baer RJ, Ryckman KK, McLemore MR, Jelliffe-Pawlowski LL. Preterm birth and nativity among Black women with gestational diabetes in California, 2013-2017: a population-based retrospective cohort study. BMC Pregnancy Childbirth 2020; 20 (01) 593
47 Valdes EG. Examining cesarean delivery rates by race: a population-based analysis using the robson ten-group classification system. J Racial Ethn Health Disparities 2021; 8 (04) 844-851
48 Getahun D, Strickland D, Lawrence JM, Fassett MJ, Koebnick C, Jacobsen SJ. Racial and ethnic disparities in the trends in primary cesarean delivery based on indications. Am J Obstet Gynecol 2009; 201 (04) 422.e1-422.e7
49 Hardeman RR, Medina EM, Kozhimannil KB. Structural racism and supporting black lives - the role of health professionals. N Engl J Med 2016; 375 (22) 2113-2115
50 Crear-Perry J, Correa-de-Araujo R, Lewis Johnson T, McLemore MR, Neilson E, Wallace M. Social and structural determinants of health inequities in maternal health. J Womens Health (Larchmt) 2021; 30 (02) 230235-230235
51 Kilbourne AM, Switzer G, Hyman K, Crowley-Matoka M, Fine MJ. Advancing health disparities research within the health care system: a conceptual framework. Am J Public Health 2006; 96 (12) 2113-2121
52 Bryant AS, Worjoloh A, Caughey AB, Washington AE. Racial/ethnic disparities in obstetric outcomes and care: prevalence and determinants. Am J Obstet Gynecol 2010; 202 (04) 335-343

Supplementary Material

Supplementary Material (PDF)