Racial/Ethnic Disparities in Intensive Care Admissions in a Pregnant and Postpartum Population, Hawai‘i, 2012-2017

Abstract

Objective Maternal morbidity and mortality is a global concern despite advances in medical care and technology and improved economic resources of nations worldwide. The primary objective of our study was to describe racial/ethnic disparities in severe maternal morbidity by using admission to an intensive care unit (ICU) as a marker. The secondary objective was to evaluate associations between patient characteristics, including obstetric outcomes, and severe maternal morbidity. Methods This retrospective cohort study used a large inpatient database to identify pregnancy and postpartum hospitalizations in Hawai‘i from January 2012 through September 2017. We evaluated associations between sociodemographic and clinical characteristics and race/ethnicity by using χ2 tests. We used multivariable logistic regression to assess associations between race/ethnicity and ICU admission. We used a post hoc analysis to assess associations between ICU admission and obstetric outcomes by race/ethnicity. Results After adjustment, we found a significantly higher ICU admission rate among Asian (adjusted odds ratio [aOR] = 1.30; 95% CI, 1.04-1.62; P = .02), Filipino (aOR = 1.45; 95% CI, 1.17-1.79; P < .001), and Native Hawaiian/Other Pacific Islander (aOR = 1.39; 95% CI, 1.15-1.68; P < .001) women compared with non-Hispanic White women. Multiple clinical characteristics and outcomes were associated with ICU admission, such as preexisting chronic conditions and pregnancy-induced hypertensive disorders. Conclusion We found that severe maternal morbidity represented by ICU admission is higher among Asian, Filipino, and Native Hawaiian/Other Pacific Islander women than among non-Hispanic White women in Hawai’i. Our findings reemphasize the need for health care providers to be vigilant in caring for members of racial/ethnic minority groups and managing their comorbidities.

Social determinants and exposure to intimate partner violence in women with severe acute maternal morbidity in the intensive care unit: a systematic review

“…Few studies examined social determinants of health among women with SAMM in the ICU, with just age routinely reported in all studies. Most did not report on socio-economic status, and in those studies that did, there was a higher proportion of women who were poorly educated, from rural areas, and with low incomes, and in high income countries, either Black/Afro-American [7,37] or others of an immigrant/minority ethnicity background [40,46]. These indicate that it is important to gain more insight into immigration background, and investigate the relevance of length of migrant status, country of birth or origin, language, and other characteristics that may contribute to access and engagement with a health care service.…”

“…Data on smoking among maternal ICU admissions were described in fourteen studies from high-income countries (Australia, Canada, Finland, Hong-Kong, Israel, New Zealand, UK and USA including Hawaii) and one upper-middle-income country (Peru), with rates from 4.0% in Hong Kong [67] to 42.0% [68] in Australia. Madan et al (2009) [41] reported that smoking was signi cantly associated with obstetric ICU admissions; but similar results were not found in the USA (37,40), UK [39] and Canada [69].…”

“…Eight were from high-income countries (Austria, Hong-Kong and USA including Hawaii), two upper-middle-income countries (Brazil and Peru) and one lower-income country (India). Substance use disorder (aOR 2.10, 95% CI 1.61, 2.74) had an increased likelihood for ICU admission among pregnant and postpartum women in Hawaii [40]. Additionally, drug dependence was signi cantly associated with maternal ICU admissions and maternal mortality in the ICU in another study undertaken in USA [36].…”

“…This latter study reported that the type of health insurance was not a risk factor for maternal ICU admission when compared with patients without ICU admission, or between women with SAMM in the ICU and maternal ICU deaths[36]. In contrast, Wanderer et al, (2013)[42] reported a higher usage rate of Medicare/Medicaid (42.4%) in obstetric ICU admissions than obstetric non-ICU admissions (36.8%); Estrada et al, (2021)[40] indicated that pregnant and postpartum women with Medicaid/Medicare had higher rates of ICU admission than those with private health insurance (aOR: 1.69, 95% CI 1.49, 1.96); andRossi et al, (2019)…”

Obstetric and perinatal racial and ethnic disparities

“…Analysis of SMM incidence timing-differences amongst racial and ethnic groups between 2010 and 2014 found that during delivery hospitalization there was a gap in SMM between non-Hispanic-White women and all others, but during the six weeks after delivery hospitalization discharge, only the Black-White gap remained [9 ▪ ]. Studies examining individual SMM indicators show that peripartum hysterectomy, perioperative blood transfusions, and intensive care unit (ICU) admissions have increased rates for Black and Hispanic women (and other non-White women) [10–12]. NIS analysis of data between 2007 and 2017 showed that Black women, compared to White women, had the highest adjusted odds of major cardiovascular events (mortality, myocardial infarction, stroke, pulmonary embolism, peripartum cardiomyopathy) among pregnant and postpartum women [13 ▪ ].…”