ABSTRACT
BACKGROUND:
Studies find that delivery
hospital explains a significant portion of the Black-
White gap in severe maternal
morbidity. No such studies have focused on the US Southeast, where racial disparities are widest, and few have examined the relative contribution of
hospital, residential, and maternal factors.
OBJECTIVE:
This study aimed to estimate the portion of
Georgia's Black-
White gap in severe maternal
morbidity during delivery through 42 days
postpartum explained by
hospital, residential, and maternal factors. STUDY
DESIGN:
Using linked
Georgia hospital discharge,
birth, and
fetal death records for 2016 through 2020, we identified 413,124 deliveries to non-
Hispanic White (229,357; 56%) or Black (183,767; 44%) individuals. We linked
hospital data from the
American Hospital Association and Center for
Medicare and
Medicaid Services, and area data from the Area
Resource File and American
Community Survey. We identified severe maternal
morbidity indicator conditions during delivery or subsequent
hospitalizations through 42 days
postpartum. Using
race-specific
logistic models followed by a decomposition
technique, we estimated the portion of the Black-
White severe maternal
morbidity gap explained by the following (1)
sociodemographic factors (age,
education,
marital status, and nativity), (2) medical conditions (
diabetes mellitus, gestational diabetes, chronic
hypertension, gestational hypertension or
preeclampsia, and
smoking), (3) obstetrical factors (singleton or multiple, and
birth order); (4)
access to care (no or
third trimester care, and payer), (5)
hospital factors that are
time-varying (delivery volume, deliveries per full-
time equivalent
nurse, doctor
communication,
patient safety, and
adverse event composite score) or measured
time-invariant characteristics (
ownership, profit status, religious affiliation,
teaching status, and perinatal level), and (6) residential factors (county urban/rural
classification, percent
uninsured women of reproductive age,
obstetrician-
gynecologists per
women of reproductive age, number of federally-qualified and
community health centers, medically-underserved area [yes/no], and
census tract neighborhood deprivation index). We estimated models with and without
hospital fixed-effects, which account for unobserved
time-invariant
hospital characteristics such as within-
hospital care processes or unmeasured
hospital-specific factors.
RESULTS:
There was 1.8 times the rate of severe maternal
morbidity per 100 discharges among non-
Hispanic Black (3.15) than among
White (1.73) individuals, with an explained proportion of 30.4% in models without and 49.8% in models with
hospital fixed-effects. In the latter,
hospital fixed-effects explained the largest portion of the Black-
White severe maternal
morbidity gap (15.1%) followed by
access to care (14.9%) and
sociodemographic factors (14.4%), with residential factors being protective for Black individuals (-7.5%). Smaller proportions were explained by medical (5.6%), obstetrical (4.0%), and
time-varying
hospital factors (3.2%). Within each category, the largest explanatory portion was payer type (13.3%) for
access to care,
marital status (10.3%) for sociodemographic,
gestational hypertension (3.3%) for medical,
birth order (3.6%) for obstetrical, and
patient safety indicator (3.1%) for
time-varying
hospital factors.
CONCLUSION:
Models with
hospital fixed-effects explain a greater proportion of
Georgia's Black-
White severe maternal
morbidity gap than models without them, thereby supporting the point that differences in care processes or other unmeasured factors within the same
hospital translate into racial differences in severe maternal
morbidity during delivery through 42 days
postpartum.
Research is needed to discern and ameliorate sources of within-
hospital differences in care. The substantial proportion of the gap attributable to racial differences in
access to care and
sociodemographic factors points to other needed
policy interventions.