Perspective

Study finds racial segregation, inequality in NICUs across the US

Photo of Erika Edwards
Erika M. Edwards

A recent study found that black, Hispanic and Asian infants were segregated in NICUs across the United States — a reflection of wider racial segregation in the country, researchers said.

“Compared to white infants, black infants were concentrated at NICUs with lower quality scores and Asian and Hispanic infants were concentrated at NICUs with higher quality scores,” Erika M. Edwards, PhD, research assistant professor at the University of Vermont and director of data science at Vermont Oxford Network, told Infectious Diseases in Children. “A hospital’s quality of care is related directly to neonatal mortality and morbidities, many of which have long-term outcomes.”

Edwards and colleagues conducted an analysis of 743 NICUs from the Vermont Oxford Network, which receives standardized data from infants born in or transferred to member NICUs in the U.S. within 28 days of birth. The study included 117,982 infants born between January 2014 and December 2016 at 401 g to 1500 g or 22 to 29 weeks’ gestation.

The researchers defined two indices — the NICU segregation index and NICU inequality index — based on the Gini coefficients associated with the corresponding Lorenz curves.

“These indices quantify the extent of segregation and inequality for black, Hispanic and Asian infants compared with white infants,” the researchers wrote.

To determine the quality of the NICUs, Edwards and colleagues used Baby-MONITOR (Measure of Neonatal Intensive Care Outcomes Research), a hospital-level composite score that compares nine measures of infant care.

Among the infants, 36,359 (31%) were black, 21,808 (18%) were Hispanic, 5,920 (5%) were Asian and 53,895 (46%) were white. Lorenz curves showed that nonwhites were segregated into different hospitals than nonwhites: 0.50 (95% CI, 0.46-0.53) for black infants, 0.58 (95% CI, 0.54-0.61) for Hispanic infants and 0.45 (95% CI, 0.4-0.5) for Asian infants.

Lorenz curves for inequality were –0.10 (95% CI, –0.17 to –0.04) for Hispanic infants, –0.26 (95% CI, –0.32 to –0.19) for Asian infants and 0.07 (95% CI, 0.02-0.13) for black infants. The inequality curves indicated that Hispanic and Asian infants were treated at higher quality NICUs than white infants and black infants were treated at lower quality NICUs.

In a related editorial, Elizabeth A. Howell, MD, MPP, director of the Blavatnik Family Women’s Health Research Institute at the Icahn School of Medicine at Mount Sinai, and colleagues said that “racial segregation and unequal access to high-quality care place black very preterm infants at a disadvantage from birth. Given the multiple cognitive, developmental and behavioral sequelae associated with neonatal morbidity among these fragile infants, early disparities in care can influence health and quality of life over the life course. We must do better.” – by Erin Michael

Disclosure: Edwards reports no relevant financial disclosures.

Photo of Erika Edwards
Erika M. Edwards

A recent study found that black, Hispanic and Asian infants were segregated in NICUs across the United States — a reflection of wider racial segregation in the country, researchers said.

“Compared to white infants, black infants were concentrated at NICUs with lower quality scores and Asian and Hispanic infants were concentrated at NICUs with higher quality scores,” Erika M. Edwards, PhD, research assistant professor at the University of Vermont and director of data science at Vermont Oxford Network, told Infectious Diseases in Children. “A hospital’s quality of care is related directly to neonatal mortality and morbidities, many of which have long-term outcomes.”

Edwards and colleagues conducted an analysis of 743 NICUs from the Vermont Oxford Network, which receives standardized data from infants born in or transferred to member NICUs in the U.S. within 28 days of birth. The study included 117,982 infants born between January 2014 and December 2016 at 401 g to 1500 g or 22 to 29 weeks’ gestation.

The researchers defined two indices — the NICU segregation index and NICU inequality index — based on the Gini coefficients associated with the corresponding Lorenz curves.

“These indices quantify the extent of segregation and inequality for black, Hispanic and Asian infants compared with white infants,” the researchers wrote.

To determine the quality of the NICUs, Edwards and colleagues used Baby-MONITOR (Measure of Neonatal Intensive Care Outcomes Research), a hospital-level composite score that compares nine measures of infant care.

Among the infants, 36,359 (31%) were black, 21,808 (18%) were Hispanic, 5,920 (5%) were Asian and 53,895 (46%) were white. Lorenz curves showed that nonwhites were segregated into different hospitals than nonwhites: 0.50 (95% CI, 0.46-0.53) for black infants, 0.58 (95% CI, 0.54-0.61) for Hispanic infants and 0.45 (95% CI, 0.4-0.5) for Asian infants.

Lorenz curves for inequality were –0.10 (95% CI, –0.17 to –0.04) for Hispanic infants, –0.26 (95% CI, –0.32 to –0.19) for Asian infants and 0.07 (95% CI, 0.02-0.13) for black infants. The inequality curves indicated that Hispanic and Asian infants were treated at higher quality NICUs than white infants and black infants were treated at lower quality NICUs.

In a related editorial, Elizabeth A. Howell, MD, MPP, director of the Blavatnik Family Women’s Health Research Institute at the Icahn School of Medicine at Mount Sinai, and colleagues said that “racial segregation and unequal access to high-quality care place black very preterm infants at a disadvantage from birth. Given the multiple cognitive, developmental and behavioral sequelae associated with neonatal morbidity among these fragile infants, early disparities in care can influence health and quality of life over the life course. We must do better.” – by Erin Michael

Disclosure: Edwards reports no relevant financial disclosures.

    Perspective
    Amaris Keiser

    Amaris Keiser

    Disparities in quality of care between racial/ethnic minorities and white individuals are well-documented, especially among adults. However, whether disparities persist among very-low-birth-weight (VLBW), preterm infants in neonatal intensive care units (NICUs) across the country is not well-defined.

    Using a database containing information from NICUs across the country, this study found (a) substantial segregation (ie, uneven distribution of patients by racial or ethnic group) across NICUs; (b) lower quality NICUs tend to cluster within certain U.S. census regions; (c) a greater likelihood that black, but not Hispanic or Asian infants, are cared for in lower quality NICUs than white infants; and (d) the higher concentration of black infants in lower quality NICUs is not explained by regional variation in NICU quality.

    Among VLBWs, we see evidence of minority infants receiving lower quality of care based on hospital metrics and a measurable degree of segregation across NICUs. Regional variation alone does not explain the extent of these differences, especially for black infants. This study speaks to the lasting impact of historical racial segregation on the quality of available health services, and it underscores the importance of targeting social structures and forces, in addition to hospitals, health care providers and systems, to improve health outcomes among minority patients. 

    • Amaris Keiser, MD
    • Assistant professor of pediatrics
      Johns Hopkins Medicine

    Disclosures: Keiser reports no relevant financial disclosures.