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dcyphr | Paradoxical Trends and Racial Differences in Obstetric Quality and Neonatal and Maternal Mortality

Abstract

In this study, the researchers wanted to understand the relationship between race, trends in the safety and quality of obstetric services, and trends in maternal and neonatal mortality. They calculated indicators of hospital quality and patient safety as well as maternal and neonatal mortality by race using data from the Nationwide Inpatient Sample from 2000 to 2009. They explored differences between black and white women for these factors, adjusted for age, comorbidities, and geographic region.

The study found that changes in the quality and safety of obstetric services differed by region but changes over time were constant for both white and black women. Cesarean deliveries (C-sections) increased for both black and white women, but more rapidly for white women. Indicators of obstetric safety improved for both black and white women, while neonatal injuries decreased. Even though these factors improved, maternal and neonatal mortality remained constant during the study period, with black women having higher rates for both than white women.

In conclusion, improvements in obstetric quality and safety do not correlate with improvements in maternal and neonatal mortality. They do not explain racial disparities for pregnancy outcomes in black and white women. More research about quality measures related to pregnancy outcomes are necessary to fully understand these disparities.

Aims

In this study, the researchers wanted to understand the relationship between improvement in safety and quality of obstetric services and maternal and neonatal mortality. They especially wanted to understand this relationship in the context of race.

Introduction

Over four million births happen every year in the U.S., and childbirth is the largest reason for hospital admission for both privately and publicly insured Americans. Complications during delivery are prevalent and are related to quality of care. There are persistent racial health disparities in maternal and neonatal mortality, in which black women are three to four times more likely to die during childbirth than white women.

Hospital quality varies from hospital to hospital and is associated with maternal and neonatal health outcomes. One third to one half of maternal deaths are preventable by quality hospital care. This gives rise to the importance of hospital care in preventing maternal and neonatal deaths and narrowing racial gaps in these deaths.

The purpose of this study was to examine differences between black and white women of seven indicators of safe and quality obstetric services. The researchers also wanted to understand geographic variations and trends in these indicators and maternal/neonatal outcomes over time. The hypothesis tested in this study was that quality and safety of obstetric services improved and decreased maternal/neonatal mortality for both black and white women.

Results

Patient safety indicators improved overall. Rates of maternal injury decreased by 28% for white women and 35% for black women. Vaginal deliveries conducted without an instrument decreased by 44% for white women and 43% for black women, and overall proportion of vaginal deliveries performed with an instrument decreased from 11% to 8%. Rates of neonatal injury decreased by 6% for black women and 21% for white women. Rates of change for these indicators were similar for black and white women except for maternal injury, which decreased more rapidly for white women.

Inpatient quality indicators also improved. Cesarean delivery rates increased while vaginal birth after Cesareans (VBACs) decreased. Cesarean deliveries increased for white women by 53% and 47% for black women. The rate of this increase was similar for both groups. However, the decline of VBACs was faster for white women than black women. VBACs decreased by 74% for white women and 66% for black women, and this decline happened earlier in the study period for white women. In addition, VBACs were higher in black women than white women throughout the study period.

Patient safety and inpatient quality indicators differed from region-to-region for black and white women, but overall trends were similar for both races.

Although patient safety and inpatient quality indicators improved over the study period, maternal and neonatal mortality did not significantly change. Rates for both kinds of mortality were persistently higher in black women, at 12.0 and 4.6 maternal deaths per 100,000 deliveries and 6.6 and 2.5 neonatal deaths per 100,000 deliveries for black and white women respectively.

Discussion

The results of this study indicate that patient safety and inpatient quality indicators improved from 2000 to 2009. However, despite these improvements, maternal and neonatal mortality remained the same.

These improvements had similar rates in both black and white women. One exception was that the rate of VBAC rates, for which decline was faster in white women than black women. This raises questions about how obstetric practices are being provided differently based on race. The cause of this finding cannot be determined in this study. The findings that black women had lower rates of maternal injury and that the rate of cesarian deliveries varies by region is consistent with previous findings.

In addition, the results of this study suggest patient safety and inpatient quality indicators are not associated with maternal and neonatal mortality. There might be more underlying factors that are more important in explaining causes of maternal and neonatal mortality. Indicators more focused on processes of care during delivery are needed and may be targets for improving neonatal and maternal outcomes.

Given that women of color account for 50% of births and are at higher risk for adverse maternal and neonatal outcomes, there is a necessity for measures sensitive to racial disparities in order for hospitals to narrow them. Further research should be done to improve existing measures and create new measures that could be used to understand what causes disparities in maternal and neonatal mortality and reduce deaths both overall and in different racial groups.

Methods

The researchers analyzed data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project from 2000-2009. They included all deliveries that happened in hospitals that had at least 10 deliveries annually to exclude any accidental births.

The researchers calculated indicators of patient safety, quality of hospital care, and neonatal and maternal mortality. Patient safety indicators included injury to either the mother or neonate. The researchers also examined four indicators for quality of hospital care that were related to obstetrics: cesarean delivery, primary cesarean, uncomplicated vaginal birth after cesarean delivery, and all vaginal births after cesarean deliveries. 

Calculations for these indicators were also adjusted for age, sex, and comorbidities. They also examined these indicators by four geographic regions: Northeast, Midwest, South, and West.

Analyses were stratified by race, specifically for black and white women. They compared adjusted calculations for quality and safety indicators for maternal/neonatal mortality for both the entire country and also by region.