Racial-ethnic segregation was as prevalent in neonatal intensive care in 2014-2016 as it was in the rest of U.S. society, researchers found, with infants in certain minority groups tending to receive care at lower-quality neonatal intensive care units (NICUs).
Among more than 700 NICUs, infants were segregated by ethnicity and race with segregation indices of 0.45 (95% CI 0.40-0.50) for Asians, 0.58 (95% CI 0.54-0.61) for Hispanics, and 0.50 (95% CI 0.46-0.53) for blacks, according to Erika Edwards, PhD, of Vermont Oxford Network in Burlington, and colleagues.
Asian and Hispanic infants were clustered at NICUs with higher-quality scores, and black infants were concentrated at NICUs with lower-quality scores, when compared with white infants. The NICU inequality index was −0.26 (95% CI −0.32 to −0.19) for Asian infants, 0.07 (95% CI 0.02-0.13) for black infants, and −0.10 (95% CI −0.17 to −0.04) for Hispanic infants, they reported in JAMA Pediatrics.
Among the census regions, there was marked variation in the weighted mean NICU quality scores, which ranged from −0.69 to 0.85. The infants’ area of residence accounted for the inequality for Hispanic infants, but not for Asian or black infants, they added.
Previous research on race/ethnicity and quality of care in the NICU has focused on California, but the present investigation extends beyond that one state, Edwards noted in an interview with MedPage Today. “The study is adding to the national conversation about differences in care by race,” she said.
The findings contribute to the growing evidence that care of infants is unequal and segregated, and adds to the “alarming and persistent disparities” in health outcomes by ethnicity and race in the U.S., agreed Elizabeth Howell, MD, MPP, of Icahn School of Medicine at Mount Sinai in New York City, and colleagues in an accompanying editorial.
These findings call attention to how limited the information is on how to address these concerns, they added.
Until now, most investigations have looked at disparities in the NICU setting using a quantitative approach. Answers are needed regarding what drives these disparities and greater understanding of the context of the variation is warranted, the editorialists emphasized.
Investigations aimed at understanding clinician, patient, community, and system factors that play a role in these disparities and that synergize attributes of both quantitative and qualitative approaches may be one technique to produce richer information as it has been implemented in other branches of medicine to better quality, they said.
Qualitative research focused on understanding variations between low-performing and high-performing facilities in constructs that are difficult to quantify, like culture, parental involvement, and communication, can inform change in different ways than quantitative data. Efforts should also be made to evaluate the quality of not only NICUs, but also obstetric units, Howell’s group noted.
“Further qualitative methods can be especially important in the setting of health disparities and allow insight into patient experience, implicit bias, and other factors,” they wrote.
The researchers assessed 117,982 infants treated in 2014-2016 at 743 NICUs (48% teaching hospitals) in the Vermont Oxford Network. The analysis included Hispanic (n=21,808), Asian (n=5,920), white (n=53,895), and black (n= 36,359) infants born at 22 to 29 weeks’ gestation or weighing 401 g to 1,500 g (<1 lb to about 3.3 lbs).
Other results from the linear regression model without adjusting for U.S. census region showed that a 10% increase in population led to Baby-MONITOR scores of 0.04 (95% CI 0.00-0.08) for Hispanics, 0.31 (95% CI 0.21-0.41) for Asians, and −0.05 (95% CI −0.08 to −0.01) for blacks.
Adjusting for the U.S., region showed a 10% increase in population with Baby-MONITOR scores of 0.02 (95% CI −0.03 to 0.06) for Hispanics, 0.14 (95% CI 0.03-0.25) for Asians, and −0.05 (95% CI −0.09 to −0.01) for blacks.
The researchers noted that the classification of ethnicity and race was based on the mother’s ethnicity and race. “Our data did not collect information on Asian and Hispanic subethnicities, and other studies have reported significant heterogeneity in health outcomes within these subgroups,” they said.
There are numerous unmeasured factors that could explain the findings of the study including immigration status, financing, hospital location, public policies, insurance coverage, and neighborhood of residence, but further research is needed to consider the effects of these factors, they stated.
“We hope that hospitals will use these findings to take a step back, and think about their own quality of care and the quality of care for every infant, and make sure that they’re providing the highest quality of care to every infant. We also hope that this sparks conversation about where infants receive care, and particularly, what happens to them after they leave the hospital,” Edwards told MedPage Today.
The study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Development.
Edwards and two co-authors disclosed relevant relationships with Vermont Oxford Network.
Howell and co-authors disclosed no relevant relationships with industry.