Sociodemographic disparities in fetal surgery for myelomeningocele: a single-center retrospective review

Abstract

OBJECTIVE Fetal surgery for myelomeningocele has become an established treatment that offers less risk of requiring a ventricular shunt and improved functional outcomes for patients. An increasing body of literature has suggested that social determinants of health have a profound influence on health outcomes. The authors sought to determine the socioeconomic and racial and ethnic backgrounds of patients who were treated with fetal surgery versus those who underwent postnatal repair. METHODS Demographic data, the method of myelomeningocele repair, insurance status, and zip code data for patients entered into the National Spina Bifida Patient Registry (NSBPR) from Children’s Wisconsin were collected. The zip code was used to determine the Distressed Communities Index (DCI) score, a composite socioeconomic ranking with scores ranging from 0 (no distress) to 100 (severe distress). The zip code was also used to determine the median household income for each patient based on the US Census Bureau 2013–2017 American Community Survey 5-year estimates. RESULTS A total of 205 patients were identified with zip code and insurance data. There were 23 patients in the fetal surgery group and 182 patients in the postnatal surgery group. All patients were born between 2000 and 2019. Patients in the fetal surgery group were more likely to have commercial insurance (100% vs 52.2%, p < 0.001). Fetal surgery patients were also more likely to be non-Hispanic White (95.7% vs 68.7%, p = 0.058), just missing the level of statistical significance. Patients who underwent fetal surgery tended to reside in zip codes with a higher median household income (mean $66,507 vs $59,133, p = 0.122) and less-distressed communities (mean DCI score 31.3 vs 38.5, p = 0.289); however, these differences did not reach statistical significance. CONCLUSIONS Patients treated with fetal surgery were more likely to have commercial insurance and have a non-Hispanic White racial and ethnic background. The preliminary data suggest that socioeconomic and racial and ethnic disparities may exist regarding access to fetal surgery, and investigation of a larger population of spina bifida patients is warranted.

Identification of micrognathia by prenatal ultrasound may improve timely diagnosis and management of infants with Robin sequence

“…This observation suggests that other confounding variables may be at play, such as insurance status limiting access to follow‐up ultrasounds, differences in the quality and interpretation of the ultrasound itself, or availability of referrals and/or transportation to a tertiary medical center for prenatal consultation. Our findings are consistent with prior studies that have shown differences in obstetric care and neonatal outcomes between those with government issued insurance and those with commercial insurance 19–21 …”

“…Our findings are consistent with prior studies that have shown differences in obstetric care and neonatal outcomes between those with government issued insurance and those with commercial insurance. [19][20][21] Our study, while one of the first of its kind to be reported, has significant limitations. Most notable is our lack of objective measurements of micrognathia and retrognathia (inferior facial angle or jaw index) for most patients.…”

Prenatal privilege: Why do people of colour have restricted access to foetal intervention?

“…Significant disparities exist. Patients with low socioeconomic status, those who lack private insurance and those who are people of colour are less likely to undergo foetal spina bifida closure (Foy et al, 2021; Wilpers et al, 2022).…”

“…Even those with access to health care encounter additional impediments to specific services. Patients of colour are twice as likely to suffer from multiple maternal comorbidities and pregnancy complications that may disqualify them from eligibility for closure (Foy et al, 2021). In my practice, maternal obesity (i.e., body mass index >40) is the most common comorbidity to impact eligibility for foetal closure, followed by high blood pressure, gestational diabetes and sexually transmitted infections.…”

“…Eligibility, a set of characteristics that must be present for foetal spina bifida closure, can be affected by physical (medical history), social (support system) and economic (medical insurance, job security) factors. What has been clear to me in my practice and what the literature confirms is that social determinants negatively impact foetal spina bifida closure eligibility (Dewan & Wellons, 2019;Foy et al, 2021). In this piece, I offer my reflections based on nearly 10 years of clinical practice in a tertiary spina bifida care centre.…”