Objectives Research has indicated that social support is a major buffer of postpartum depression. Yet little is known concerning women’s perceptions on social support during the postpartum period. The objective of this study was to explore postpartum women’s views and experiences with social support following childbirth. Methods Four focus groups were conducted with an ethnically diverse sample of women (n=33) in a large urban teaching hospital in New York City. Participants had completed participation in a postpartum depression randomized trial and were 6 to 12 months postpartum. Data transcripts were reviewed and analyzed for themes. Results The main themes identified in the focus group discussions were mother’s major needs and challenges postpartum, social support expectations and providers of support, how mothers mobilize support, and barriers to mobilizing support. Women across all groups identified receipt of instrumental support as essential to their physical and emotional recovery. Support from partners and families was expected and many women believed this support should be provided without asking. Racial/ethnic differences existed in the way women from different groups mobilized support from their support networks. Conclusions Instrumental support plays a significant role in meeting women’s basic needs during the postpartum period. In addition, women’s expectations surrounding support can have an impact on their ability to mobilize support among their social networks. The results of this study suggest that identifying support needs and expectations of new mothers is important for mothers’ recovery after childbirth. Future postpartum depression prevention efforts should integrate a strong focus on social support.

BACKGROUND For every maternal death, over 100 women experience severe maternal morbidity, a life threatening diagnosis or undergo a life-saving procedure, during their delivery hospitalization. Similar to racial/ethnic disparities in maternal mortality, black women are more likely to suffer from severe maternal morbidity than white women. Site of care has received attention as a mechanism explaining disparities in other areas of medicine. Data indicate that blacks receive care in a concentrated set of hospitals and these hospitals appear to provide lower quality of care. Whether racial differences in site of delivery contribute to observed black-white disparities in severe maternal morbidity rates is unknown. OBJECTIVE To determine whether hospitals with high proportions of black deliveries have higher severe maternal morbidity and if 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 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 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, p<.001); after adjusting for the distribution of patient characteristics and comorbidities, this differential declined, but remained elevated (18.8 vs. 13.3per 1000 deliveries respectively, p<.001). Women delivering 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, 19.4, versus 12.2 per 1000 deliveries respectively, p<0 .001) and adjusted analyses (17.3, 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.

BACKGROUND The black-white maternal mortality disparity is the largest disparity among all conventional population perinatal health measures and the mortality gap between black and white women in New York City has nearly doubled in recent years. For every maternal death, 100 women experience severe maternal morbidity, a life threatening diagnosis or undergo a lifesaving procedure during their delivery hospitalization. Like maternal mortality, severe maternal morbidity is more common among black than white women. A significant portion of maternal morbidity and mortality is preventable making quality of care in hospitals a critical lever for improving outcomes. Hospital variation in risk-adjusted severe maternal morbidity rates exists. The extent to which variation in hospital performance on severe maternal morbidity rates contributes to black-white disparities in New York City hospitals has not been studied. OBJECTIVE We examined the extent to which black-white differences in severe maternal morbidity rates in New York City hospitals can be explained by differences in the hospitals in which black and white women deliver. STUDY DESIGN We conducted a population-based study using linked 2011–2013 New York City discharge and birth certificate datasets (N= 353,773 deliveries) to examine black-white differences in severe maternal morbidity rates in New York City hospitals. Mixed-effects logistic regression with a random hospital-specific intercept was used to generate risk-standardized severe maternal morbidity rates for each hospital (N=40). We then assessed differences in the distributions of black and white deliveries among these hospitals. RESULTS Severe maternal morbidity occurred in 8,882 deliveries (2.5%) and was higher among black than white women (4.2% vs. 1.5%, p<.001). After adjustment for patient characteristics and comorbidities the risk remained elevated for black women (odds ratio=2.02; 95% CI 1.89–2.17). Risk-standardized severe maternal morbidity rates among New York City hospitals ranged from 0.8 to 5.7 per 100 deliveries. White deliveries were more likely to be delivered in low morbidity hospitals: 65% of white versus 23% of black deliveries occurred in hospitals in the lowest tertile for morbidity. We estimated that black-white differences in delivery location may contribute as much as 47.7% of the racial disparity in severe maternal morbidity rates in New York City. CONCLUSION Black mothers are more likely to deliver at higher risk-standardized severe maternal morbidity hospitals than are white mothers, contributing to black-white disparities. More research is needed to understand the attributes of high performing hospitals and to share best practices among hospitals.

IMPORTANCE Substantial quality improvements in neonatal care have occurred over the past decade yet racial and ethnic disparities in morbidity and mortality remain. It is uncertain whether disparate patterns of care by race and ethnicity contribute to disparities in neonatal outcomes. OBJECTIVES To examine differences in neonatal morbidity and mortality rates among non-Hispanic black (black), Hispanic, and non-Hispanic white (white) very preterm infants and to determine whether these differences are explained by site of delivery. DESIGN, SETTING, AND PARTICIPANTS Population-based retrospective cohort study of 7177 nonanomalous infants born between 24 and 31 completed gestational weeks in 39 New York City hospitals using linked 2010 to 2014 New York City discharge abstract and birth certificate data sets. Mixed-effects logistic regression with a random hospital-specific intercept was used to generate risk-adjusted neonatal morbidity and mortality rates for very preterm infants in each hospital. Hospitals were ranked using this measure, and differences in the distribution of black, Hispanic, and white very preterm births were assessed among these hospitals. The statistical analysis was performed in 2016-2017. EXPOSURE Race/ethnicity. MAIN OUTCOMES AND MEASURES Composite of mortality (neonatal or in-hospital up to 1 year) or severe neonatal morbidity (bronchopulmonary dysplasia, severe necrotizing enterocolitis, retinopathy of prematurity stage 3 or greater, or intraventricular hemorrhage grade 3 or greater). RESULTS Among 7177 very preterm births (VPTBs), morbidity and mortality occurred in 2011 (28%) and was higher among black (893 [32.2%]) and Hispanic (610 [28.1%]) than white (319 [22.5%]) VPTBs (2-tailed P < .001). The risk-standardized morbidity and mortality rate was twice as great for VPTB infants born in hospitals in the highest morbidity and mortality tertile (0.40; 95% CI, 0.38-0.41) as for those born in the lowest morbidity and mortality tertile (0.16; 95% CI, 0.14-0.18). Black (1204 of 2775 [43.4%]) and Hispanic (746 of 2168 [34.4%]) VPTB infants were more likely than white (325 of 1418 [22.9%]) VPTB infants to be born in hospitals in the highest morbidity and mortality tertile (2-tailed P < .001; black-white difference, 20%; 95% CI, 18%-23% and Hispanic-white difference, 11%; 95% CI, 9%-14%). The largest proportion of the explained disparities can be attributed to differences in infant health risks among black, Hispanic, and white VPTB infants. However, 40% (95% CI, 30%-50%) of the black-white disparity and 30% (95% CI, 10%-49%) of the Hispanic-white disparity was explained by birth hospital. CONCLUSIONS AND RELEVANCE Black and Hispanic VPTB infants are more likely to be born at hospitals with higher risk-adjusted neonatal morbidity and mortality rates, and these differences contribute to excess morbidity and mortality among black and Hispanic infants.

To explore important domains of women’s postpartum experiences as perceived by postpartum mothers and obstetricians/midwives, and to investigate how postpartum care could enhance patient preparation for the postpartum period. Qualitative research study was conducted to explore women’s and clinicians’ perceptions of the postpartum experience. Four focus groups of postpartum women (n = 45) and two focus groups of obstetric clinicians (n = 13) were held at a large urban teaching hospital in New York City. All focus groups were audio recorded, transcribed, and analyzed using grounded theory. Four main themes were identified: lack of women’s knowledge about postpartum health and lack of preparation for the postpartum experience, lack of continuity of care and absence of maternal care during the early postpartum period, disconnect between providers and postpartum mothers, and suggestions for improvement. Mothers did not expect many of the symptoms they experienced after childbirth and were disappointed with the lack of support by providers during this critical time in their recovery. Differences existed in the major postpartum concerns of mothers and clinicians. However, both mothers and clinicians agreed that preparation during the antepartum period could be beneficial for postpartum recovery. Results from this study indicate that many mothers do not feel prepared for the postpartum experience. Study findings raise the hypothesis that capturing patient-centered domains that define the postpartum experience and integrating these domains into patient care may enhance patient preparation for postpartum recovery and improve postpartum outcomes.