Mount Sinai researchers find black and Latina mothers experience higher rates of severe maternal morbidity as compared with white mothers within the same hospital, with insurance status not responsible for these disparities.
Paper title: Race and Ethnicity, Medical Insurance, and Within-Hospital Severe Maternal Morbidity Disparities
Corresponding author: Elizabeth A. Howell, MD, MPP, Professor, Population Health Science and Policy, and Obstetrics, Gynecology, and Reproductive Science, and Director of The Blavatnik Family Women's Health Research Institute, Icahn School of Medicine at Mount Sinai
Topic: Contribution of Race and Ethnicity and Medical Insurance to Within-Hospital Disparities in Severe Maternal Morbidity in New York City Hospitals.
What: Our objective was to examine within-hospital racial and ethnic disparities in severe maternal morbidity rates and to determine whether they are associated with differences in types of medical insurance.
When: We conducted a population-based, cross sectional study using linked 2010-2014 New York City discharge and birth certificate data sets.
Who: The sample included 591,455 deliveries and 40 hospitals. We examined within-hospital black-white, Latina-white, and Medicaid-commercially insured differences in severe maternal morbidity.
Results: Severe maternal morbidity was higher among black and Latina than white women (4.2% and 2.9% vs.1.5%, respectively, p<.001) and among women insured by Medicaid than those commercially insured (2.8% vs. 2.0%, p<.001). Women insured by Medicaid versus those with commercial insurance had similar risk for severe maternal morbidity within the same hospital (p=.54). In contrast, black versus white women had significantly higher risk for severe maternal morbidity within the same hospital (p<.001) as did Latina women (p<0.001). Conditional logit analyses confirmed these findings with black and Latina versus white women having higher risk for severe maternal morbidity (adjusted odds ratio=1.52; 95% CI 1.46-1.62 and adjusted odds ratio=1.44; 95% CI 1.36-1.53, respectively) and women insured by Medicaid compared to those commercially insured having similar risk.
Why the research is interesting: There is growing attention on the maternal health care crisis, our high rates of maternal mortality in the United States, and the persistent racial and ethnic disparities in maternal mortality and severe maternal morbidity that exist in this country. In this paper, we set out to measure within-hospital racial and ethnic disparities and to evaluate the potential contribution of insurance status to these disparities. Our study question was based on the observation that women with Medicaid can follow different care pathways than women with private insurance. Pregnant women insured by Medicaid are often seen by resident physicians with attending coverage that may differ from attending physicians caring for commercially insured women. In addition, Medicaid reimbursement for delivery hospitalization is far less than reimbursements by commercial insurers.
Our data demonstrate that black and Latina women are more likely than white women to experience severe maternal morbidity within the same hospital after accounting for patient sociodemographic and clinical characteristics, but insurance status was not responsible for these disparities. Our findings are consistent with other research demonstrating that socioeconomic status does not explain racial/ethnic disparities in severe maternal morbidity. Our findings raise the hypothesis that other factors, such as implicit bias, communication skills, structural racism, and different care patterns, may contribute to racial and ethnic disparities within hospitals.
Background: Previous research, including our own, has demonstrated racial and ethnic disparities in severe maternal morbidity rates in hospitals, and that between-hospital differences-;i.e., black and Latina mothers receiving care at hospitals with worse outcomes-;explain a sizable portion of these disparities. However, less attention has been paid to within-hospital disparities-;whether black and Latina mothers have worse outcomes than white mothers who deliver in the same hospital. In this paper, we set out to measure within-hospital racial and ethnic disparities and to evaluate the potential contribution of insurance status to these disparities.
Medicaid covers nearly half of the deliveries in the United States and black and Latina pregnant women are more likely to be insured by Medicaid than are white pregnant women. Growing attention has focused on the potential contribution of Medicaid to racial and ethnic disparities in maternal health outcomes for a few reasons. First, pregnant women insured by Medicaid are often seen by resident physicians with attending coverage that may differ from attending physicians caring for commercially insured women. Second, Medicaid reimbursement for delivery hospitalization is far less than that for commercially insured. To our surprise, our data do not suggest that any differences in treatment patterns were reflected in worse outcomes for Medicaid-covered and commercially insured mothers within the same hospital. These results indicate that pathways other than insurance are responsible for the higher risks of severe maternal morbidity among black and Latina versus white women that were observed in our study.
Said Mount Sinai's Dr. Elizabeth Howell about the research:
Previous research has documented that a sizable portion of racial and ethnic disparities in severe maternal morbidity rates were explained by between-hospital differences-;i.e., black and Latina mothers receiving care at hospitals that generally show worse outcomes. Our study demonstrates that even within the same hospital, black and Latina mothers experience higher rates of severe maternal morbidity as compared with white mothers and these disparities are not explained by differences in type of insurance. Our findings raise the hypothesis that other factors, such as implicit bias, communication skills, structural racism, and different care patterns, may contribute to our findings of racial and ethnic disparities within hospitals.
Funding: This study was funded by the National Institute on Minority Health and Health Disparities (R01MD007651)
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