Racial Segregation and Inequality in the Neonatal Intensive Care Unit for Very Low-Birth-Weight and Very Preterm Infants

Abstract

IMPORTANCE Racial and ethnic minorities receive lower-quality health care than white non-Hispanic individuals in the United States. Where minority infants receive care and the role that may play in the quality of care received is unclear. OBJECTIVE To determine the extent of segregation and inequality of care of very low-birth-weight and very preterm infants across neonatal intensive care units (NICUs) in the United States. DESIGN, SETTING, AND PARTICIPANTS This cohort study of 743 NICUs in the Vermont Oxford Network included 117 982 black, Hispanic, Asian, and white infants born at 401 g to 1500 g or 22 to 29 weeks’ gestation from January 2014 to December 2016. Analysis began January 2018. MAIN OUTCOMES AND MEASURES The NICU segregation index and NICU inequality index were calculated at the hospital level as the Gini coefficients associated with the Lorenz curves for black, Hispanic, and Asian infants compared with white infants, with NICUs ranked by proportion of white infants for the NICU segregation index and by composite Baby-MONITOR (Measure of Neonatal Intensive Care Outcomes Research) score for the NICU inequality index. RESULTS Infants (36 359 black [31%], 21 808 Hispanic [18%], 5920 Asian [5%], and 53 895 white [46%]) were segregated among the 743 NICUs by race and ethnicity (NICU segregation index: black: 0.50 [95% CI, 0.46–0.53], Hispanic: 0.58 [95% CI, 0.54–0.61], and Asian: 0.45 [95% CI, 0.40–0.50]). Compared with white infants, black infants were concentrated at NICUs with lower-quality scores, and Hispanic and Asian infants were concentrated at NICUs with higher-quality scores (NICU inequality index: black: 0.07 [95% CI, 0.02–0.13], Hispanic: −0.10 [95% CI, −0.17 to −0.04], and Asian: −0.26 [95% CI, −0.32 to −0.19]). There was marked variation among the census regions in weighted mean NICU quality scores (range: −0.69 to 0.85). Region of residence explained the observed inequality for Hispanic infants but not for black or Asian infants. CONCLUSIONS AND RELEVANCE Black, Hispanic, and Asian infants were segregated across NICUs, reflecting the racial segregation of minority populations in the United States. There were large differences between geographic regions in NICU quality. After accounting for these differences, compared with white infants, Asian infants received care at higher-quality NICUs and black infants, at lower-quality NICUs. Explaining these patterns will require understanding the effects of sociodemographic factors and public policies on hospital quality, access, and choice for minority women and their infants.

The color of health: how racism, segregation, and inequality affect the health and well-being of preterm infants and their families

“…Evidence over the past two decades has documented that black very low birth weight (VLBW) infants are cared for in a concentrated set of hospitals 64 and that minority-serving hospitals have higher neonatal mortality rates for both black and white infants. 65,66 More recent research has expanded beyond mortality to include severe neonatal morbidities with similar findings.…”

“…69 Recent investigations utilizing national data found significant segregation across NICUs and that black infants received care at lower-quality NICUs. 64 These studies suggest that improving care provided at lower-quality hospitals would result in a significant narrowing of disparities. 66 While previous studies primarily investigated between-hospital disparities, additional research has examined within-hospital disparities.…”

Multilevel social factors and NICU quality of care in California

“…Finally, findings are restricted to California and generalizability to other states is unknown. In fact, a recent study highlighted the comparatively better outcomes for minority groups in California [8]. Most of the social factors in this study are derived from national data sets and could thus be replicated.…”

“…This work adds to the literature examining the relationship of factors at various levels and NICU quality. In a study among NICUs in the VON, Black infants were concentrated at NICUs with lower quality scores, and Hispanic and Asian infants were at NICUs with higher quality scores, compared with White infants [8]. Racial/ethnic disparities in morbidity and mortality among very preterm infants in New York City were attributable to both infant factors and birth hospital implying hospital level factors may contribute to inequities in outcomes among NICU patients [46].…”

“…Although overall outcomes and equities have improved [4], inequities in care delivery have been demonstrated to exist. Vulnerable populations are segregated into lower quality NICUs [5][6][7][8][9] and within NICUs they tend to receive lower quality of care, particularly less family-centered care [10]. Recent studies have created multifaceted activities centered around using quality improvement (QI) strategies to address equity in care delivery.…”