Background
For every maternal death, >100 women experience severe maternal morbidity, which is
a life-threatening diagnosis, or undergo a life-saving procedure during their delivery
hospitalization. Similar to racial/ethnic disparities in maternal death, black women
are more likely to experience severe maternal morbidity than white women. Site of
care has received attention as a mechanism to explain disparities in other areas of
medicine. Data indicate that black women receive care in a concentrated set of hospitals
and that these hospitals appear to provide lower quality of care. Whether racial differences
in the site of delivery contribute to observed black-white disparities in severe maternal
morbidity rates is unknown.
Objective
The purpose of this study was to determine whether hospitals with high proportions
of black deliveries have higher severe maternal morbidity and whether such differences
contribute to overall black-white disparities in severe maternal morbidity.
Study Design
We used a published algorithm to identify cases of severe maternal morbidity during
deliveries in the Nationwide Inpatient Sample of the Healthcare Cost and Utilization
Project for 2010 and 2011. We ranked hospitals by their proportion of black deliveries
into high black-serving (top 5%), medium black-serving (5% to 25% range), and low
black-serving hospitals. We analyzed the risks of severe maternal morbidity for black
and white women by hospital black-serving status using logistic regressions that were
adjusted for patient characteristics, comorbidities, hospital characteristics, and
within-hospital clustering. We then derived adjusted rates from these models.
Results
Seventy-four percent of black deliveries occurred at high and medium black-serving
hospitals. Overall, severe maternal morbidity occurred more frequently among black
than white women (25.8 vs 11.8 per 1000 deliveries, respectively; P < .001); after adjustment for the distribution of patient characteristics and comorbidities,
this differential declined but remained elevated (18.8 vs 13.3 per 1000 deliveries,
respectively; P < .001). Women who delivered in high and medium black-serving hospitals had elevated
rates of severe maternal morbidity rates compared with those in low black-serving
hospitals in unadjusted (29.4 and 19.4 vs 12.2 per 1000 deliveries, respectively;
P < .001) and adjusted analyses (17.3 and 16.5 vs 13.5 per 1000 deliveries, respectively;
P < .001). Black women who delivered at high black-serving hospitals had the highest
risk of poor outcomes.
Conclusion
Most black deliveries occur in a concentrated set of hospitals, and these hospitals
have higher severe maternal morbidity rates. Targeting quality improvement efforts
at these hospitals may improve care for all deliveries and disproportionately impact
care for black women.
Key words
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Article info
Publication history
Published online: August 14, 2015
Accepted:
August 10,
2015
Received in revised form:
July 2,
2015
Received:
April 29,
2015
Footnotes
Supported by the National Institute on Minority Health and Health Disparities (R01MD007651) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R21HD068765).
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
The authors report no conflict of interest.
Cite this article as: Howell EA, Egorova N, Balbierz A, et al. Black-white differences in severe maternal morbidity and site of care. Am J Obstet Gynecol 2016;214:122.e1-7.
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© 2016 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
