Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA.
Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA.
Am J Obstet Gynecol. 2021 Feb;224(2):219.e1-219.e15. doi: 10.1016/j.ajog.2020.08.017. Epub 2020 Aug 13.
Birth hospital has recently emerged as a potential key contributor to disparities in severe maternal morbidity, but investigations on its contribution to racial and ethnic differences remain limited.
We leveraged statewide data from California to examine whether birth hospital explained racial and ethnic differences in severe maternal morbidity.
This cohort study used data on all births at ≥20 weeks gestation in California (2007-2012). Severe maternal morbidity during birth hospitalization was measured using the Centers for Disease Control and Prevention index of having at least 1 of the 21 diagnoses and procedures (eg, eclampsia, blood transfusion, hysterectomy). Mixed-effects logistic regression models (ie, women nested within hospitals) were used to compare racial and ethnic differences in severe maternal morbidity before and after adjustment for maternal sociodemographic and pregnancy-related factors, comorbidities, and hospital characteristics. We also estimated the risk-standardized severe maternal morbidity rates for each hospital (N=245) and the percentage reduction in severe maternal morbidity if each group of racially and ethnically minoritized women gave birth at the same distribution of hospitals as non-Hispanic white women.
Of the 3,020,525 women who gave birth, 39,192 (1.3%) had severe maternal morbidity (2.1% Black; 1.3% US-born Hispanic; 1.3% foreign-born Hispanic; 1.3% Asian and Pacific Islander; 1.1% white; 1.6% American Indian and Alaska Native, and Mixed-race referred to as Other). Risk-standardized rates of severe maternal morbidity ranged from 0.3 to 4.0 per 100 births across hospitals. After adjusting for covariates, the odds of severe maternal morbidity were greater among nonwhite women than white women in a given hospital (Black: odds ratio, 1.25; 95% confidence interval, 1.19-1.31); US-born Hispanic: odds ratio, 1.25; 95% confidence interval, 1.20-1.29; foreign-born Hispanic: odds ratio, 1.17; 95% confidence interval, 1.11-1.24; Asian and Pacific Islander: odds ratio, 1.26; 95% confidence interval, 1.21-1.32; Other: odds ratio, 1.31; 95% confidence interval, 1.15-1.50). Among the studied hospital factors, only teaching status was associated with severe maternal morbidity in fully adjusted models. Although 33% of white women delivered in hospitals with the highest tertile of severe maternal morbidity rates compared with 53% of Black women, birth hospital only accounted for 7.8% of the differences in severe maternal morbidity comparing Black and white women and accounted for 16.1% to 24.2% of the differences for all other racial and ethnic groups.
In California, excess odds of severe maternal morbidity among racially and ethnically minoritized women were not fully explained by birth hospital. Structural causes of racial and ethnic disparities in severe maternal morbidity may vary by region, which warrants further examination to inform effective policies.
最近，分娩医院被认为是导致严重产妇发病率差异的一个潜在关键因素，但对其导致种族和民族差异的贡献的研究仍然有限。
我们利用加利福尼亚州的全州数据，研究分娩医院是否解释了严重产妇发病率的种族和民族差异。
本队列研究使用了加利福尼亚州≥20 周妊娠的所有分娩数据（2007-2012 年）。通过使用疾病控制和预防中心的指数来衡量分娩住院期间的严重产妇发病率，该指数至少有 21 种诊断和手术之一（例如子痫、输血、子宫切除术）。采用混合效应逻辑回归模型（即，嵌套在医院内的女性），比较了调整产妇社会人口统计学和妊娠相关因素、合并症和医院特征之前和之后的严重产妇发病率的种族和民族差异。我们还估算了每个医院（n=245）的风险标准化严重产妇发病率和如果每个少数民族裔群体的女性在与非西班牙裔白人女性相同的医院分布中分娩，则严重产妇发病率降低的百分比。
在 3020525 名分娩的女性中，有 39192 名（1.3%）患有严重产妇发病率（黑人 2.1%；美国出生的西班牙裔 1.3%；外国出生的西班牙裔 1.3%；亚洲和太平洋岛民 1.3%；白人 1.1%；美洲印第安人和阿拉斯加原住民和混血儿被称为其他 1.6%）。风险标准化的严重产妇发病率在各医院之间从每 100 例出生 0.3 例到 4.0 例不等。在调整了协变量后，与白人女性相比，同一医院的非白人女性发生严重产妇发病率的几率更高（黑人：比值比，1.25；95%置信区间，1.19-1.31）；美国出生的西班牙裔：比值比，1.25；95%置信区间，1.20-1.29；外国出生的西班牙裔：比值比，1.17；95%置信区间，1.11-1.24；亚洲和太平洋岛民：比值比，1.26；95%置信区间，1.21-1.32；其他：比值比，1.31；95%置信区间，1.15-1.50）。在所研究的医院因素中，只有教学地位在完全调整的模型中与严重产妇发病率相关。尽管与黑人女性相比，33%的白人女性在严重产妇发病率最高的三分之一的医院分娩，而黑人女性的比例为 53%，但分娩医院仅解释了黑人女性和白人女性之间严重产妇发病率差异的 7.8%，并解释了所有其他种族和族裔群体之间严重产妇发病率差异的 16.1%至 24.2%。
在加利福尼亚州，少数族裔女性严重产妇发病率的额外几率不能完全用分娩医院来解释。严重产妇发病率的种族和民族差异的结构性原因可能因地区而异，这需要进一步研究，以为制定有效的政策提供信息。
