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?