A recent study published in JAMA Network Open has shed light on significant racial and ethnic disparities in obstetric care within the United States. The research highlights inequalities in the quality of hospitals where individuals give birth, with a particular focus on comparing the quality of the actual delivery hospital with that of the nearest obstetric hospital to the birthing individual’s residence.
Study Design and Methodology
The study was a population-based retrospective cohort study that looked at data from five states: California, Michigan, Oregon, Pennsylvania, and South Carolina. The data included birth and fetal death certificates linked to maternal hospital records, focusing on deliveries with gestational ages between 22 and 44 weeks. The researchers examined the racial and ethnic distribution of 6,418,635 birthing individuals and assessed hospital quality using the standardized morbidity ratio (SMR) for nontransfusion severe maternal morbidity (SMM).
To evaluate disparities, the study compared the quality of the hospital where the birth occurred with that of the nearest hospital to the birthing individual’s residential zip code centroid. Inequality was measured using Gini coefficients and Lorenz curves, with a focus on comparing outcomes for American Indian, Asian, Black, and Hispanic individuals against those for White individuals.
Key Findings
The study showed significant racial and ethnic disparities in the quality of delivery hospitals.
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American Indian and Black individuals were found to deliver at lower-quality hospitals compared with White individuals.
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Conversely, no significant difference in delivery hospital quality was observed for Asian and Hispanic individuals compared with White individuals.
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Black individuals were found to live closer to lower-quality hospitals than White individuals.
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The study also found that the disparity in care between Black and White individuals would be reduced if Black individuals delivered at the nearest hospital to their residence.
“In all five states in our study, Black birthing individuals lived closer to higher quality hospitals than the hospitals they chose for delivery,” the researchers wrote in the study’s discussion. “The reasons that pregnant individuals select certain hospitals are not well understood. Area-level factors, such as geographic proximity, structural racism, insurance status and comorbidities, might be determinants of access to care. The percentage of office-based physicians accepting new Medicaid patients (69 percent) for example, has been shown to be lower than the percentage accepting new Medicare patients (84 percent) or new privately insured patients (85 percent), indicating that insurance type might limit access to certain hospitals that differ on quality of care provided.”
Implications for Clinical Practice and Policy
These findings have important implications for healthcare providers and policymakers. The observed disparities in delivery hospital quality highlight the impact of systemic inequities in healthcare access and delivery.
For clinicians, it is crucial to be aware of these disparities and their potential impact on maternal health outcomes. Understanding the role of factors such as geographic proximity, structural racism, insurance status, and comorbidities in influencing hospital choice can aid in providing more equitable care.
Policymakers should consider interventions aimed at improving the quality of care at hospitals serving minoritized populations and addressing the systemic factors that contribute to healthcare segregation. Strategies to reduce residential segregation and ensure equitable access to high-quality care, regardless of race or ethnicity, are essential.
Limitations
The authors acknowledged several limitations to their study. These include the lack of data on factors influencing individual hospital choice, potential unmeasured confounders in hospital quality risk adjustment, and the use of zip code centroids rather than geocoded addresses, which could introduce measurement error. However, they noted that this measurement error is unlikely to significantly bias the results.
Final notes
This study provides compelling evidence of racial and ethnic disparities in the quality of hospitals where individuals deliver. The findings underscore the urgent need for targeted interventions and policy changes to address these inequities and improve maternal health outcomes for all individuals.