Evaluation of Patient Access to Spanish-Language-Concordant Care on a Postpartum Unit.

OBJECTIVE: To evaluate patient access to Spanish-language-concordant care on a postpartum unit and to identify facilitators and barriers to the use of interpretation services. DESIGN: Mixed-methods research study, comprising a cross-sectional chart review from September to December 2019 and semistructured interviews from June to December 2020. SETTING/LOCAL PROBLEM: A tertiary academic medical center in the southeastern United States where individuals with limited English proficiency are at risk for poor health outcomes when they are unable to communicate with clinicians in their preferred language. PARTICIPANTS: We conducted a chart review of 50 randomly selected birthing parent-newborn couplets and interviews with 14 inpatient health care team members. MEASUREMENTS: The chart review examined patient characteristics, health care team composition including Spanish language proficiency, length of stay, number of interpreter requests, and time between clinician interpreter requests and interpreter arrival on the unit. Interviews evaluated facilitators and barriers to interpreter use. RESULTS: Access to a clinician certified in medical Spanish or an interpreter was offered to 12 of 50 (24%) couplets upon admission to the unit and to 7 of 50 (14%) of couplets for daily maternal and newborn medical rounds. Clinicians reported long and unpredictable wait times to access interpreters, which led them to rely on hand gestures, broken Spanish, and smartphone apps to "get by" when communicating with patients without certified interpretation services. Participants described low usage of interpreters for "noncritical" encounters. CONCLUSION: Interpreters and other forms of Spanish-language-concordant care were underused on the postpartum unit. This deviation from national standards may put families at risk for harm. Recommendations from this study include advancing a culture of respectful care, improving the interpreter request workflow, addressing safe staffing, facilitating direct patient access to interpreters, and providing ongoing evaluation and support.

Racial Disparities in the Rates of and Indications for Cesarean Delivery in California: Are They Changing Over Time?

OBJECTIVE: The aim of this study was to assess whether racial disparities in rates of and indications for cesarean delivery (CD) between non-Hispanic Black and non-Hispanic White birthing people in California changed from 2011 to 2017. METHODS: This was a retrospective cohort study using a database of birth certificates linked to discharge records. Singleton term live births in nulliparous Black and White birthing people in California between 2011 and 2017 were included. Those with noncephalic presentation, placenta previa, and placenta accreta were excluded. CD rate and indication were obtained from birth certificate variables and International Classification of Diseases codes. Differences in CD rate and indication were calculated for Black versus White individuals using univariable and multivariable logistic regression and adjusted for potential confounders. RESULTS: A total of 348,144 birthing people were included, 46,361 Black and 301,783 White. Overall, 30.9% of Black birthing people underwent CD compared with 25.3% of White (adjusted relative risk [aRR]: 1.2, 95% confidence interval [CI]: 1.2-1.3). From 2011 to 2017, the CD rate fell 11% (26.4-23.7%, p < 0.0001) for White birthing people and 1% for Black birthing people (30.4-30.1%, p = 0.037). Over the study period, Black birthing people had a persistent 1.2- to 1.3-fold higher risk of CD and were persistently more likely to undergo CD for fetal intolerance (aRR: 1.1, 95% CI: 1.1-1.2) and less likely for active phase arrest or arrest of descent (aRRs: 0.9 and 0.4; 95% CIs: 0.9-0.9 and 0.3-0.5). CONCLUSION: The CD rate decreased substantially for White birthing people and minimally for Black birthing people in our cohort over the study period. Meanwhile, disparities in CD rate and indications between the two groups persisted, despite controlling for confounders. Although care bundles for reducing CD may be effective among White birthing people, they are not associated with reduction in CD rates among Black birthing people nor improvements in racial disparities between Black and White birthing people. PRECIS: Despite increasing attention to racial inequities in obstetric outcomes, there were no changes in disparities in CD rates or indications in California from 2011 to 2017. KEY POINTS: · Black birthing people are more likely to undergo CD than White despite controlling for confounders.. · There are unexplained differences in CD indication among Black and White birthing people.. · These disparities persisted from 2011 to 2017 despite increasing efforts to decrease CD rates in CA..