Elizabeth A. Howell

Objective To determine whether delivery hospitals that perform poorly for women also perform poorly for high-risk infants and to what extent Black and Hispanic women receive care at hospitals that perform poorly for both women and infants. Methods We examined the correlation between hospital rankings for severe maternal morbidity and very preterm morbidity and mortality in New York City Hospitals using linked birth certificate and state discharge data for 2010–2014. We used mixed-effects logistic regression with a random hospital-specific intercept to generate risk standardized severe maternal morbidity rates and very preterm birth neonatal morbidity and mortality rates for each hospital. We ranked hospitals separately by these risk-standardized rates. We used k-means cluster analysis to categorize hospitals based on their performance on both metrics and risk-adjusted multinomial logistic regression to estimate adjusted probabilities of delivering in each hospital-quality cluster by race/ethnicity. Results Hospital rankings for severe maternal morbidity and very preterm neonatal morbidity-mortality were moderately correlated (r = .32; p = .05). A 5-cluster solution best fit the data and yielded the categories for hospital performance for women and infants: excellent, good, fair, fair to poor, poor. Black and Hispanic versus White women were less likely to deliver in an excellent quality cluster (adjusted percent of 11%, 18% vs 28%, respectively, p < .001) and more likely to deliver in a poor quality cluster (adjusted percent of 28%, 20%, vs. 4%, respectively, p < .001). Conclusions for Practise Hospital performance for maternal and high-risk infant outcomes is only moderately correlated but Black and Hispanic women deliver at hospitals with worse outcomes for both women and very preterm infants.

OBJECTIVE: To examine within-hospital racial and ethnic disparities in severe maternal morbidity rates and determine whether they are associated with differences in types of medical insurance. METHODS: We conducted a population-based, cross-sectional study using linked 2010–2014 New York City discharge and birth certificate data sets (N=591,455 deliveries) to examine within-hospital black–white, Latina–white, and Medicaid–commercially insured differences in severe maternal morbidity. We used logistic regression to produce risk-adjusted rates of severe maternal morbidity for patients with commercial and Medicaid insurance and for black, Latina, and white patients within each hospital. We compared these within-hospital adjusted rates using paired t-tests and conditional logit models. RESULTS: Severe maternal morbidity was higher among black and Latina women than white women (4.2% and 2.9% vs 1.5%, respectively, P<.001) and among women insured by Medicaid than those commercially insured (2.8% vs 2.0%, P<.001). Women insured by Medicaid compared with those with commercial insurance had similar risk for severe maternal morbidity within the same hospital (P=.54). In contrast, black women compared with white women had significantly higher risk for severe maternal morbidity within the same hospital (P<.001), as did Latina women (P<.001). Conditional logit analyses confirmed these findings, with black and Latina women compared with white women having higher risk for severe maternal morbidity (adjusted odds ratio [aOR] 1.52; 95% CI 1.46–1.62 and aOR 1.44; 95% CI 1.36–1.53, respectively) and women insured by Medicaid compared with those commercially insured having similar risk. CONCLUSION: Within hospitals in New York City, black and Latina women are at higher risk of severe maternal morbidity than white women; this is not associated with differences in types of insurance.

Racial/ethnic disparities persist in obstetrical outcomes. In this paper, we ask how research in obstetrical quality can go beyond a purely quantitative approach to tackle the challenge of health inequity in quality and safety. This overview debriefs the use of positive deviance and mixed methods in others areas of medicine, describes the shortcomings of quantitative methods in obstetrics and presents qualitative studies carried out in obstetrics as well as the insights provided by this method. The article concludes by proposing positive deviance as a mixed methods approach to generate new knowledge for addressing racial and ethnic disparities in maternal outcomes.

Significant racial and ethnic disparities in maternal morbidity and mortality exist in the United States. Black women are 3 to 4 times more likely to die a pregnancy-related death as compared with white women. Growing research indicates that quality of health care, from preconception through postpartum care, may be a critical lever for improving outcomes for racial and ethnic minority women. This article reviews racial and ethnic disparities in severe maternal morbidities and mortality, underlying drivers of these disparities, and potential levers to reduce their occurrence.

Racial and ethnic disparities exist in both perinatal outcomes and health care quality. For example, black women are three to four times more likely to die from pregnancy-related causes and have more than a twofold greater risk of severe maternal morbidity than white women. In an effort to achieve health equity in maternal morbidity and mortality, a multidisciplinary workgroup of the National Partnership for Maternal Safety, within the Council on Patient Safety in Women's Health Care, developed a concept article for the bundle on reduction of peripartum disparities. We aimed to provide health care providers and health systems with insight into racial and ethnic disparities in maternal outcomes, the etiologies that are modifiable within a health care system, and resources that can be used to address these etiologies and achieve the desired end of safe and equitable health care for all childbearing women.

Racial and ethnic disparities exist in both perinatal outcomes and health care quality. For example, black women are 3 to 4 times more likely to die from pregnancy‐related causes and have more than a 2‐fold greater risk of severe maternal morbidity than white women. In an effort to achieve health equity in maternal morbidity and mortality, a multidisciplinary workgroup of the National Partnership for Maternal Safety, within the Council on Patient Safety in Women's Health Care, developed a concept article for the bundle on reduction of peripartum disparities. We aimed to provide health care providers and health systems with insight into racial and ethnic disparities in maternal outcomes, the etiologies that are modifiable within a health care system, and resources that can be used to address these etiologies and achieve the desired end of safe and equitable health care for all childbearing women.

Substantial improvements in neonatal care have been documented over the past decade.¹ From 2005 to 2014, rates of death before discharge and serious morbidities decreased among neonatal intensive care units (NICUs) in the United States; by 2014, most NICUs achieved rates of performance equivalent to the best quartile of the 2005 benchmark.^1,2 In fact, 98% of NICUs achieved the risk-adjusted rate of mortality of the best 10% of units in 2005.² Despite these improvements, wide variation in mortality and serious morbidities exist across NICUs.^1,3,4

(Abstracted from JAMA Pediatr 2017;171(7):678–686) Prenatal administration of antenatal corticosteroids (ANSs) reduces neonatal morbidity and mortality in preterm infants and is recommended for women at risk of delivery before 34 weeks' gestation. There is consensus that neonatal benefits are maximized when ANSs are administered 24 hours to 7 days before delivery, but the latest point at which ANSs can be used effectively is unknown.