Health disparities begin early for preemies

Emily Willingham

About Emily Willingham

Emily Willingham (@ejwillingham) is AHCJ's core topic leader on the social determinants of health. She is a science journalist whose work has appeared in the Washington Post, San Francisco Chronicle, Wall Street Journal, Scientific American, and Forbes, among others, and co-author of "The Informed Parent: A Science-Based Guide to Your Child's First Four Years."

In the United States, health disparities related to race and ethnicity start early. A study published March 25 in JAMA Pediatrics has found very-low-birth weight and very-preterm infants are segregated by race and ethnicity in neonatal intensive care units (NICUs). Black babies tend to be treated in NICUs that offer lower-quality care. Infants of Asian and Hispanic ethnicity receive care at NICUs known for best-quality care, and white infants fall in between these extremes.

The authors, from several U.S. universities and hospitals, say that the segregation in the NICU reflects broader social patterns in the United States. Indeed, NICU quality varies by geography and well as by populations treated in them. Yet where a child was born affected NICU quality of care only for Hispanic infants. Geography did not play a role in the lower-quality care that black infants received or the higher-quality care that infants of Asian ancestry received. That points to human, rather than locational, factors.

An accompanying editorial says that these findings are “alarming” but “not surprising” because of research across all areas of medicine showing disparities based on race and ethnicity. Across the board, black patients have a cluster of hospitals where they tend to receive care, and that care tends to be of poorer quality, leading not surprisingly to higher mortality.

Journalists have a dyadic story to pursue here: that of the mother and child and their fates in US hospitals, determined by social factors that these institutions and the people who form them seem powerless to uproot. The editorial accompanying this study of 117,982 infants says that “the fact that some of our most fragile infants are subject to unequal care is unacceptable” and that “we must do better,” but it offers little in the way of a roadmap beyond calling for more studies.

In her April 2018 examination of a similar pattern of outcome disparities for black women giving birth in U.S. hospitals, Linda Villarosa of the New York Times Magazine includes the story of Simone Landrum. Landrum, pregnant and on Medicaid for insurance, found her obvious symptoms of pre-eclampsia dismissed time and again weeks ahead of her due date. Not until she began to hemorrhage from a prematurely separated placenta did clinicians take note—and by then, Landrum was in the hospital. Her baby, Harmony, was stillborn via cesarean delivery.

Black infants die at rates twice that of white infants, and black mothers have three to four times the risk of mortality related to pregnancy compared to white mothers. This latest JAMA Pediatrics study adds another horrific entry into the ledger tracking this human toll of social factors in health.

Villarosa’s piece is thorough and comprehensive, but clearly, there are more stories to tell, including stories about what’s being done to address these disparities and who’s doing it. Some items to pursue:

  • What is access like in your region? Who has access to which facilities?
  • What is the quality rating of those facilities, and what makes a NICU “poor” vs. “good” quality?
  • Are facilities in the area aware of these disparities, and if so, what explicit steps are they taking to address them.
  • What are the gaps in care that social factors drive?
  • What are ways that women seek to fill that gap, including midwives and other forms of care?
  • The JAMA Pediatrics study suggests disparities that begin in infancy, but obviously, for the mothers, they are an ongoing series of access and quality-care issues. Where does the gap begin to widen in pregnancy — is it prenatal visit access, work and other factors that interfere?
  • On the other end of the care spectrum in the JAMA Pediatrics study are babies of Asian and Hispanic ethnicity. What social factors are involved in their more positive, differential access to care and outcomes?

4 thoughts on “Health disparities begin early for preemies

  1. Roxanne Nelson

    I just took a glance at this study, and will read it ii more detail, but it seems to imply that some sort of intentional segregation is going on. For one thing, black girls born at very low birthweights are more than twice as likely to survive as compared with white males. This is supported by literature as well as decades of observation by NICU staff. They do better period. As someone who worked in the NICU for 15 years, in several states and in all sorts of hospitals, I can attest to that. So have they looked at this phenomena of how well black girls do? I think not.

    Second, the idea of “segregation.” A baby will end up in a specific NICU depending on a variety of factors–where the mom gave birth, how much care the infant needs, the insurance, and geography. The study says that ” Black, Hispanic, and Asian infants were distributed unevenly across NICUs compared with white infants.” Well of course they are distributed unevenly, whites are still the overwhelming majority population in this country, and minorities do not have an even distribution, ie, more blacks in the south, Asians in California and Seattle, etc. So of course there are going to be differences. Asians tend to live in urban areas, where there are large medical centers, for example, so a premie is likely to end up at one.

    “The fact that some of our most fragile infants are subject to unequal care is unacceptable.” Everyone in this country is subject to unequal care, for all the factors that I named above. Seriously, so what do they propose to do about it? Most families don’t want their infant to be transported 100 miles away if their is a NICU closer, and that is what it may come down to. Nobody is forcibly “segregating” minorities, which is what this study makes it sound like. If geography doesn’t play a role for the supposed lower quality of care that a black infant gets, or that they end up in “inferior” NICUs, then what does? I have yet to see any discrimination in the NICU, and depending on the hospital and location, there was an assortment of all kinds of infants, in every color and ethnicity. I would say that insurance could play a role, but virtually all medical centers will take Medicaid infants, so that isn’t as strong factor.

    I will have to read this study more carefully, but it seems very dubious to me–especially when they say that geography plays no role.

  2. Roxanne Nelson

    I found that just a little hard to believe, that these infants are getting inferior care based on race. As I said, the choice of NICU depends largely where the mother gives birth, and that choice is made by location, insurance, where her doctor/midwife has privileges, etc. If she lives in a poor neighborhood and goes to the county hospital, then maybe the NICU there is underfunded and understaffed–but that has to do with socioeconomic status and not race. Are these authors saying that in a city with 3 NICUs all near eachother (so geography doesn’t play a role), the black infants are going to be routed to the poorest care? Seriously? Who is doing that? This study sounds nice and dramatic as disparities in healthcare are an issue, but their conclusions are just short of ridiculous. And those are the questions that journalists should be asking–how can there be “segregation” of sick infants, unless they are forcibly being sent to inferior locations.

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