Trends in racial/ethnic disparities in postpartum hospital readmissions in California from 1997 to 2018.

BACKGROUND: Postpartum readmission is an important indicator of postpartum morbidity. The likelihood of postpartum readmission is highest for Black individuals. However, it is unclear whether the likelihood of postpartum readmission has changed over time according to race/ethnicity. Little is also known about the factors that contribute to these trends. OBJECTIVE: This study aimed to: (1) examine trends in postpartum readmission by race/ethnicity, (2) examine if prenatal or clinical factors explain the trends, and (3) investigate if racial/ethnic disparities changed over time. STUDY DESIGN: We examined trends in postpartum readmission, defined as hospitalization within 42 days after birth hospitalization discharge, using live birth and fetal death certificates linked to delivery discharge records from 10,711,289 births in California from 1997 to 2018. We used multivariable logistic regression models that included year and year-squared (to allow for nonlinear trends), overall and stratified by race/ethnicity, to estimate the annual change in postpartum readmission during the study period, represented by odds ratios and 95% confidence intervals. We then adjusted models for prenatal (eg, patient demographics) and clinical (eg, gestational age, mode of birth) factors. To determine whether racial/ethnic disparities changed over time, we calculated risk ratios for 1997 and 2018 by comparing the predicted probabilities from the race-specific, unadjusted logistic regression models. RESULTS: The overall incidence of postpartum readmission was 10 per 1000 births (17.4/1000 births for non-Hispanic Black, 10/1000 for non-Hispanic White, 7.9/1000 for non-Hispanic Asian/Pacific Islander, and 9.6/1000 for Hispanic individuals). Odds of readmission increased for all groups during the study period; the increase was greatest for Black individuals (42% vs 21%-29% for the other groups). After adjustment for prenatal and clinical factors, the increase in odds was similar for Black and White individuals (12%). The disparity in postpartum readmission rates relative to White individuals increased for Black individuals (risk ratio, 1.68 in 1997 and 1.90 in 2018) and more modestly for Hispanic individuals (risk ratio, 1.02 in 1997 and 1.05 in 2018) during the study period. Asian/Pacific Islander individuals continued to have lower risk than White individuals during the study period (risk ratio, 0.87 in 1997 and 0.82 in 2018). CONCLUSION: The rate of postpartum readmissions increased from 1997 to 2018 in California across all racial/ethnic groups, with the greatest increase observed for Black individuals. Racial/ethnic differences in the trend were more modest after adjustment for prenatal and clinical factors. It is important to find ways to prevent further increases in postpartum readmission, especially among groups at highest risk.

Co-occurrence of mental illness and substance use among US pregnant individuals, 2012-2021.

AIM: Substance use disorders are increasingly prevalent among pregnant individuals, with evident risks of adverse perinatal outcomes. This study examines substance use (tobacco, alcohol and marijuana) among pregnant individuals with mental illness. METHODS: A national representative sample of pregnant individuals were derived from 2012 to 2021 National Survey of Drug Use and Health data. Associations of past-year mental illness with past-month polysubstance use and each substance use were analyzed by logistic regression models, with complex sampling weights and survey year. RESULTS: Among 6801 pregnant individuals, 16.4% reported having any mental illness (AMI) in 2012 and 2013, increasing to 23.8% in 2020-2021; and SMI increased from 3.3% to 9.4%. Polysubstance use increased disproportionately among those with severe mental illness (SMI), from 14.0% to 18.6%. Pregnant individuals with greater severity of mental illness had higher odds of polysubstance use (Adjusted Odds Ratio, 95% CI: AMI but no SMI vs. without AMI: 1.59 [1.04, 2.44]; SMI vs. without AMI: 5.48 [2.77, 10.82]). CONCLUSIONS: Pregnant individuals with greater severity of mental illness were more likely to engage in substance use. Evidence-based educational, screening and treatment services, and public policy changes are warranted to mitigate the harmful health outcomes of substance use among US pregnant individuals with mental illness.

Hospital-level variation in racial disparities in low-risk nulliparous cesarean delivery rates.

BACKGROUND: Nationally, rates of cesarean delivery are highest among Black patients compared with other racial/ethnic groups. These observed inequities are a relatively new phenomenon (in the 1980s, cesarean delivery rates among Black patients were lower than average), indicating an opportunity to narrow the gap. Cesarean delivery rates vary greatly among hospitals, masking racial disparities that are unseen when rates are reported in aggregate. OBJECTIVE: This study aimed to explore reasons for the current large Black-White disparity in first-birth cesarean delivery rates by first examining the hospital-level variation in first-birth cesarean delivery rates among different racial/ethnic groups. We then identified hospitals that had low first-birth cesarean delivery rates among Black patients and compared them with hospitals with high rates. We sought to identify differences in facility or patient characteristics that could explain the racial disparity. STUDY DESIGN: A population cross-sectional study was performed on 1,267,493 California live births from 2018 through 2020 using birth certificate data linked with maternal patient discharge records. Annual nulliparous term singleton vertex cesarean delivery (first-birth) rates were calculated for the most common racial/ethnic groups statewide and for each hospital. Self-identified race/ethnicity categories as selected on the birth certificate were used. Relative risk and 95% confidence intervals for first-birth cesarean delivery comparing 2019 with 2015 were estimated using a log-binomial model for each racial/ethnic group. Patient and hospital characteristics were compared between hospitals with first-birth cesarean delivery rates <23.9% for Black patients and hospitals with rates ≥23.9% for Black patients. RESULTS: Hospitals with at least 30 nulliparous term singleton vertex Asian, Black, Hispanic, and White patients each were identified. Black patients had a very different distribution, with a significantly higher rate (28.4%) and wider standard deviation (7.1) and interquartile range (6.5) than other racial groups (P<.01). A total of 29 hospitals with a low first-birth cesarean delivery rate among Black patients were identified using the Healthy People 2020 target of 23.9% and compared with 106 hospitals with higher rates. The low-rate group had a cesarean delivery rate of 19.9%, as opposed to 30.7% in the higher-rate group. There were no significant differences between the groups in hospital characteristics (ownership, delivery volume, neonatal level of care, proportion of midwife deliveries) or patient characteristics (age, education, insurance, onset of prenatal care, body mass index, hypertension, diabetes mellitus). Among the 106 hospitals that did not meet the target for Black patients, 63 met it for White patients with a mean rate of 21.4%. In the same hospitals, the mean rate for Black patients was 29.5%. Among Black patients in the group that did not meet the 23.9% target, there were significantly higher rates of all cesarean delivery indications: labor dystocia, fetal concern (spontaneous labor), and no labor (eg, macrosomia), which are all indications with a high degree of subjectivity. CONCLUSION: The statewide cesarean delivery rate of Black patients is significantly higher and has substantially greater hospital variation compared with other racial or ethnic groups. The lack of difference in facility or patient characteristics between hospitals with low cesarean delivery rates among Black patients and those with high rates suggests that unconscious bias and structural racism potentially play important roles in creating these racial differences.

Using medical expenditure panel survey data to explore the relationship between patient-centered medical homes and racial disparities in severe maternal morbidity outcomes.

BACKGROUND: There are persistent racial/ethnic disparities in the occurrence of severe maternal morbidity. Patient-centered medical home care has the potential to address disparities in maternal outcomes. OBJECTIVES: To examine (1) the association between receiving patient-centered medical home care and severe maternal morbidity outcomes and (2) the interaction of race/ethnicity on patient-centered medical home status and severe maternal morbidity. DESIGN/METHODS: Using 2007 to 2016 data from the Medical Expenditures Panel Survey, we conducted a cross-sectional study to estimate the association between receipt of care from a patient-centered medical home and the occurrence of severe maternal morbidity, and racial-specific (White, Black, Asian, Other) relative risks of severe maternal morbidity. Our study used race as a proxy measure for exposure racism. We identified mothers (⩾15 years) who gave birth during the study period. We identified patient-centered medical home qualities using 11 Medical Expenditures Panel Survey questions and severe maternal morbidities using medical claims, and calculated generalized estimating equation models to estimate odds ratios of severe maternal morbidity and 95% confidence intervals. RESULTS: Among all mothers who gave birth (N = 2801; representing 5,362,782 US lives), only 25% received some exposure patient-centered medical home care. Two percent experienced severe maternal morbidity, and this did not differ statistically (p = 0.11) by patient-centered medical home status. However, our findings suggest a 85% decrease in the risk of severe maternal morbidity among mothers who were defined as always attending a patient-centered medical home (odds ratios: 0.15; 95% confidence interval:0.01-1.87; p = 0.14) and no difference in the risk of severe maternal morbidity among mothers who were defined as sometimes attending a patient-centered medical home (odds ratios: 1.00; 95% confidence interval:0.16-6.42; p = 1.00). There was no overall interaction effect in the model between race and patient-centered medical home groups (p = 0.82), or ethnicity and patient-centered medical home groups (p = 0.62) on the severe maternal morbidity outcome. CONCLUSION: While the rate of severe maternal morbidity was similar to US rates, few mothers received care from a patient-centered medical home which may be due to underreporting. Future research should further investigate the potential for patient-centered medical home-based care to reduce odds of severe maternal morbidity across racial/ethnic groups.

Remapping racial and ethnic inequities in severe maternal morbidity: The legacy of redlining in California.

BACKGROUND: Historical mortgage redlining, a racially discriminatory policy designed to uphold structural racism, may have played a role in producing the persistently elevated rate of severe maternal morbidity (SMM) among racialised birthing people. OBJECTIVE: This study examined associations between Home-Owner Loan Corporation (HOLC) redlining grades and SMM in a racially and ethnically diverse birth cohort in California. METHODS: We leveraged a population-based cohort of all live hospital births at ≥20 weeks of gestation between 1997 and 2017 in California. SMM was defined as having one of 21 procedures and diagnoses, per an index developed by Centers for Disease Control and Prevention. We characterised census tract-level redlining using HOLC's security maps for eight California cities. We assessed bivariate associations between HOLC grades and participant characteristics. Race and ethnicity-stratified mixed effects logistic regression models assessed the risk of SMM associated with HOLC grades within non-Hispanic Black, Asian/Pacific Islander, American Indian/Alaskan Native and Hispanic groups, adjusting for sociodemographic information, pregnancy-related factors, co-morbidities and neighbourhood deprivation index. RESULTS: The study sample included 2,020,194 births, with 24,579 cases of SMM (1.2%). Living in a census tract that was graded as "Hazardous," compared to census tracts graded "Best" and "Still Desirable," was associated with 1.15 (95% confidence interval [CI] 1.03, 1.29) and 1.17 (95% CI 1.09, 1.25) times the risk of SMM among Black and Hispanic birthing people, respectively, independent of sociodemographic factors. These associations persisted after adjusting for pregnancy-related factors and neighbourhood deprivation index. CONCLUSIONS: Historical redlining, a tool of structural racism that influenced the trajectory of neighbourhood social and material conditions, is associated with increased risk of experiencing SMM among Black and Hispanic birthing people in California. These findings demonstrate that addressing the enduring impact of macro-level and systemic mechanisms that uphold structural racism is a vital step in achieving racial and ethnic equity in birthing people's health.

Current Resources for Evidence-Based Practice, March 2022.

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of systemic racism and its effect on maternal health in the United States and commentaries on reviews focused on barriers and facilitators to HPV vaccination and delayed cord clamping in preterm infants.

Experiences of African Americans Living With Sickle Cell Disease.

INTRODUCTION: About 100,000 individuals in the United States live with sickle cell disease (SCD). Palliative care (PC) can improve symptom management for these individuals. The purpose of the study was to explore (a) the experiences of people living with SCD, and (b) their knowledge and perceptions of PC. METHOD: Using a qualitative, descriptive design, adults with SCD were recruited from a foundation in the southeastern United States. Data included social and SCD-related demographics and audio-recorded, semi-structured focus groups. Analysis took a thematic analysis approach. RESULTS: Participants: There were 16 African Americans who participated in the study, 75% of whom were females, and aged 22 to 71 years. Five themes were identified: unique and unpredictable impact of SCD on daily life, the changing experience of SCD over time, stigmatization/marginalization in health care interactions, perceptions of support in managing SCD symptoms/crises, and PC: "What is it?" DISCUSSION: Participants lacked PC knowledge. PC should be offered to individuals with SCD as part of comprehensive SCD management.

A Mixed-Methods Feasibility Study of Breastfeeding Attitudes among Southern African Americans.

We assessed the feasibility and acceptability of examining breast/chest feeding attitudes among African Americans in South Carolina using an explanatory sequential, mixed methods approach. We surveyed 50 pregnant African American women during their ob-gyn appointment (Phase I), followed by qualitative interviews with four African American couples (N = 8) (Phase II), and integrating quantitative-qualitative data through joint display (Phase III). Phase I supported the feasibility of recruiting pregnant African American women for our study. However, for Phase II, more research is needed to support the feasibility of recruiting couples from the quantitative phase. The Iowa Infant Feeding Attitude Scale demonstrated moderate reliability (α = 0.68). Participants intending to exclusively breastfeed (M = 65, SD = 5.79) had higher scores than those intending to exclusively use formula (M = 50, SD = 4.37, p < .001). The six qualitative themes (Phase II) and data integration (Phase III) identified cultural considerations for future research.

Group Prenatal Care and Maternal Outcomes: A Scoping Review.

PURPOSE: The objective of this study was to examine the current state of literature on group prenatal care and its impact on maternal outcomes and racial disparities in adverse maternal outcomes. DESIGN: We conducted a scoping review of literature published between January 2010 and December 2020 using the PRISMA-ScR reporting checklist. METHODS: Eligible studies were identified using key words and MeSH terms in PubMed, CINAHL, and Web of Science. Inclusion criteria were studies that were (a) conducted in the United States; (b) published between January 2010 and December 2020; (c) in English; (d) focused on the primary investigation of group prenatal care and reporting on maternal comorbidity outcomes; and (e) an observational study or clinical trial. RESULTS: Nine studies met inclusion criteria. They reported on outcomes of preeclampsia, gestational hypertension, gestational diabetes mellitus, final A1C among patients with gestational diabetes mellitus, and postpartum hemorrhage. None reported on racial disparities for minoritized populations. Among all reported maternal outcomes, results were mixed, providing inconclusive evidence. CLINICAL IMPLICATIONS: Outcomes from group prenatal care focus more on neonatal outcomes than maternal outcomes. More studies are needed with stronger designs. Given pervasive racial disparities in U.S. maternal mortality, future studies should assess how group prenatal care participation may contribute to fewer experiences of racial discrimination and implicit bias for Black women in maternity care.