Racial Disparity in Care Starts With Youngest, Frailest Patients
Many studies have uncovered racial gaps in health care in the United States, but now a new review confirms that the disparity begins at birth.
The review, of 41 studies, found that infants born to minority women typically received poorer care in the neonatal intensive care unit (NICU) compared with white newborns.
The finding was often related to lower-quality care in hospitals where minorities made up a large share of patients. But studies have also found treatment disparities within the same NICU.
"We're trained to treat everyone the same, and many of us believe that we do," said senior researcher Dr. Jochen Profit, an associate professor of pediatrics at Stanford University, in California.
But, he said, "NICUs don't exist in a vacuum," and can be subject to the same biases seen everywhere else.
In general, the review found, black preterm infants were most vulnerable: Hospitals with a high percentage of black preemies typically had lower-quality care and fewer nurses, versus those with a smaller percentage of black patients. There was also evidence that newborn death rates were higher in those "minority-serving" NICUs.
It's a pattern that played out in a recent study of 700 NICUs, where researchers found that black preemies were concentrated in centers with lower-quality care -- compared with white, Asian and Hispanic babies.
Quality of care was ranked according to factors like newborn death rates, and the risk of a preemie developing infections, lung problems or hypothermia (a sudden drop in body temperature).
What's going on? Part of the problem is lack of resources and understaffing at minority-serving hospitals, according to Profit.
But, he said, there are also racial disparities in care "processes." In some studies, for example, parents of black and Hispanic preemies were less likely to get referrals for follow-up care after their NICU discharge, compared with whites.
And over the years, one critical gap has been in the use of surfactant therapy, according to Dr. Wanda Barfield, of the U.S. Centers for Disease Control and Prevention.
Normally, the body produces its own surfactant, a liquid that coats the lungs and keeps them from collapsing. When babies are born before the lungs have fully developed, surfactant replacement therapy can be lifesaving, Barfield explained.
But some studies have found that black preemies were less likely to receive surfactant than white newborns.
According to Barfield, there has historically been a "myth" that black preemies have a more positive outlook, versus other groups. That's rooted in a statistic: At any given birth weight, except for the tiniest newborns, black babies tend to have better survival rates.
But such broad patterns should not affect care decisions for any one baby, Barfield said.
She wrote an editorial published online with the review July 29 in Pediatrics.
Besides some differences in treatment, the review also found that minority families tended to be less satisfied with their NICU experience. Studies have found that black mothers are less likely to be breastfeeding when their baby is discharged from the NICU -- and that those moms reported less education and support for breastfeeding, both before and after giving birth.
In one study, black women were more likely to say they were discouraged from "kangaroo care" -- having daily skin-to-skin contact with their newborn that, among other benefits, encourages breastfeeding.
Often, minority parents feel like they're "not being heard," Barfield said.
Profit agreed. In some cases, he said, there are language barriers. Other times, NICU staff might misunderstand situations: If, for example, family members aren't at the hospital often -- because of problems with transportation or getting time off from work -- some staff might judge that.
One way to address the issue is to ensure that minority-serving hospitals are part of regional quality-improvement efforts, Barfield said.
California, for instance, has the Perinatal Quality Care Collaborative. Profit said it has launched a "health equity" task force to address disparities in NICU care.
For now, he encouraged women to ask questions, starting in pregnancy, about where they'll deliver.
Barfield agreed. In some cases, she said, women who are high risk for preterm delivery -- because of a past one, for instance -- may be able to visit the NICU in the hospital where they'll deliver and ask questions.
"For some hospitals, you can find ratings or rankings," Barfield noted. "You can also ask whether [the center] has participated in any quality-improvement initiatives."
According to the latest CDC figures, the rate of preterm birth among U.S. black women remains about 50% higher than that of white women -- at 14%, versus 9%.
The CDC has more on preterm birth.
SOURCES: Jochen Profit, M.D., M.P.H., associate professor, pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, Calif.; Wanda Barfield, M.D., M.P.H., director, division of reproductive health, National Center for Chronic Disease Prevention and Health Promotion, U.S. Centers for Disease Control and Prevention, Atlanta; July 29, 2019, Pediatrics, online