Published Monday in the journal Pediatrics, the report examines more than 18,000 of the smallest babies born in 134 neonatal intensive care units (NICUs) across the Golden State, establishing a framework in which researchers can compare the health outcomes of infants based on race and ethnicity.
The report identifies differences in care that, while not uniform, do demonstrate underlying inequity in care among infants from vulnerable populations.
“There’s a long history of disparity in health care delivery, and our study shows that the NICU is really no different,” said lead author Jochen Profit, an associate professor of pediatrics at Stanford University.
The team found that in general, hospitals with the best health outcomes for patients also provide better care for white babies, while black and Hispanic infants were more likely to be treated at NICUs of lesser quality.
“Unconscious social biases that we all have can make their way into the NICU,” Profit said. “We would like to encourage NICU caregivers to think about how these disparities play out in their own units and how they can be reduced.”
The study relies on data from the California Perinatal Quality Care Collaborative (CPQCC), which includes information on about 95 percent of premature births in the state. The research focused on babies born at under 3.3 pounds, a category referred to as very low birth weight, between 2010 and 2014. The report did not include babies born extremely premature – before 24 weeks of pregnancy – or infants that had congenital abnormalities or those who died within 12 hours of birth.
The team used an index known as Baby-MONITOR, which they had previously developed to measure NICU care. To use Baby-MONITOR, each baby’s medical records are reviewed and scored based on nine yes-or-no questions that have been previously shown to reflect quality of medical care.
Some of the questions evaluate whether patients received components of NICU care that are in line with standard medical practices for premature infants, including receiving steroids before birth to help stimulate lung growth. Other questions address specific medical outcomes, such as growing at a healthy rate or contracting a hospital-acquired infection. The questionnaire was worded so that better outcomes produced higher scores.
Scores were adjusted to reflect the length of the mother’s pregnancy, whether the baby was from a single or multiple birth, whether the mother received prenatal care and whether the infant was delivered by cesarean section.
The analysis also adjusts scores to reflect that some NICUs cared for sicker babies, on average, than others. The final score for each hospital, and its group of patients, shows whether the NICU did the same, better or worse than would be expected in treating the infants. The report calculated separate scores for white, Hispanic, Asian and black babies.
Hispanic infants and those with “other” ethnicity had lower scores than white babies, while Asian and black infants did not show dramatically different scores than white babies. At the state level, however, white babies scored higher across several measures of medical care. For example, about 89 percent of white infants and 88 percent of Asian babies in the study received steroids before birth to develop their lungs. Only about 85 percent of black infants got the same treatment.
Black babies showed higher levels of chronic lung disease and lower rates of receiving any human milk at discharge when compared to white infants, both indicators of worse outcomes. Hispanic babies scored significantly lower than white infants in all aspects, except for collapsed-lung rates.
The researchers also noted that NICUs that provided the worst quality of care overall tended to have the smallest differences between ethnicities, and in some instances black infants fared better than white infants. On the other hand, hospitals with higher quality scores featured more significant disparities based on race or ethnicity, according to the study.
While racial and ethnic differences in NICU care were fairly minor when examined at the state level, the team found that some individual hospitals had major gaps in how they cared for infants from different backgrounds.
In order to address these disparities, the team calls for hospitals to adjust their care to reflect the racial and ethnic makeup of their patients.
“It’s really important for NICUs to individualize care to the patient population they see,” Profit said.
Hispanic families who primarily speak Spanish could face a language barrier that prevents parents from asking important questions, for example.
“For them, having access to translation and personnel who speak Spanish is really critical,” Profit said.
The team says the next step is to help NICUs determine specific approaches that can allow for more equitable treatment of infants. Such feedback will be addressed by the California Perinatal Quality Care Collaborative, which has developed successful quality-improvement initiatives to aid hospitals in California in efforts to improve the care they provide. The researchers are also working with the Vermont Oxford Network, a sister organization that monitors NICUs throughout the nation to offer similar feedback nationwide.
“We need to continue to identify vulnerable populations, make sure they get their needs met and find better ways to engage all families in our care,” Profit said.
Health disparities experienced by minority infants extends beyond the newborn period, according to Profit, who estimates that biological and socioeconomic differences likely play a bigger role. Nevertheless, these such factors should not overshadow the observed disparities in medical care, he said.
“For many of these infants, their time in the NICU sets them on track for their entire life,” Profit said. “If we can get things right early on, that could have a huge long-term effect.”