Matern Child Health J (2008) 12:452–460 DOI 10.1007/s10995-007-0280-6
Perinatal Disparities for Black Mothers and Their Newborns Ian M. Paul Æ Erik B. Lehman Æ Alawia K. Suliman Æ Marianne M. Hillemeier
Published online: 22 August 2007 Ó Springer Science+Business Media, LLC 2007
Abstract Objectives In the United States, significant ethnic and racial health and healthcare disparities exist among our most vulnerable populations, new mothers and newborns. We sought to determine disparities in socioeconomic status, perinatal health, and perinatal healthcare for black mothers and their newborns cared for in wellbaby nurseries compared with white mother/baby pairs in Pennsylvania. Methods A retrospective analysis of a merged data set containing birth and clinical discharge records was conducted. Perinatal data from 44,105 black mothers and their singleton newborns, 35 weeks gestational age cared for in Pennsylvania well-baby nurseries from 1998–2002 were compared with 88,210 white mother/baby pairs. Results Black mothers were younger and were much more likely to receive Medicaid or be uninsured compared with white mothers. They were less likely to be college-educated, married, or have prenatal care beginning in the first trimester. Infants born to black mothers were less likely to be delivered via Cesarean section, but were more likely to be born between 35 and 38 weeks gestation and be of low birth weight. Conclusions Numerous significant disparities exist for black
I. M. Paul (&) A. K. Suliman Department of Pediatrics, Penn State University College of Medicine, Pediatrics, H085, 500 University Dr., Hershey, PA 17033, USA e-mail:
[email protected] I. M. Paul E. B. Lehman M. M. Hillemeier Department of Public Health Sciences, Penn State University College of Medicine, Hershey, PA, USA M. M. Hillemeier Department of Health Policy and Administration, Penn State University College of Health and Human Development, University Park, PA, USA
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mothers and their newborns cared for in well-baby nurseries in Pennsylvania. Since most newborns are cared for in this setting as opposed to intensive care environments, recognition of the differences that exist for this group when compared to well newborns of white mothers can help to improve healthcare and its delivery to this population. Federal and local initiatives must continue efforts to eliminate racial disparities. Keywords Pregnancy
Health disparities Newborns Mothers
Abbreviations AAP American Academy of Pediatrics PDOH Pennsylvania Department of Health PHC4 Pennsylvania Health Care Cost Containment Council LOS Length of stay
Introduction It is widely recognized that significant ethnic and racial health and healthcare disparities exist in the United States (U.S.) [1–4]. These disparities are also known to affect our most vulnerable populations, new mothers and their newborns, and the U.S. Department of Health and Human Services specifically cite perinatal racial and ethnic disparities as a target for improvement in their publication, Healthy People 2010 [1]. Clearly demonstrating these disparities, blacks have significantly higher fetal, neonatal, infant, and maternal mortality rates compared with whites [5–8] Black/white infant mortality disparities are seen not only in low birth
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weight infants, but among those with normal birth weights as well [9]. Blacks also have higher rates of other perinatal morbidities and socioeconomic characteristics associated with adverse pregnancy outcomes. Examples of this include a high teen birth rate, a high rate of births to unmarried mothers, increased preterm delivery, and the delivery of low birth weight infants [7, 10, 11] The differences in outcomes may be partially attributable to a lack of or suboptimal prenatal care, which is known to occur more frequently among U.S. resident blacks [7, 12–15]. While disparities in preterm birth and low birth weight for blacks have been the subject of numerous reports, less attention has been paid to differences among black and white newborns cared for in non-intensive care environments. Even with the higher rate of preterm delivery known to occur for black mothers, the vast majority of black newborns will be cared for in well baby nurseries. Black mothers are more likely to feel that they or their newborns are unready to go home at the time of hospital discharge [16], and therefore, the differences between black mothers and newborns and their white counterparts in these care settings require exploration. As such, we sought to determine perinatal health and healthcare disparities between black and white mothers and their newborns 35 weeks gestational age cared for in non-intensive care newborn nurseries in Pennsylvania between 1998 and 2002. Because maternity and nursery hospital stays after pregnancies average about two days nationally, there is limited time for inpatient evaluation and detection of differential risks. A description of these differences could serve to increase provider awareness of the disparities that exist among infants in newborn nurseries and lead to improved pre and postnatal care for black mothers and their newborns. These analyses could help public or private agencies or organizations seeking to reduce racial disparities target areas for intervention.
Methods Subjects 521,656 birth records from singleton newborns 35 weeks gestation born in Pennsylvania between 1998 and 2002 were obtained from the Pennsylvania Department of Health (PDOH) birth registry for retrospective analysis. 418,991 (80.3%) of these birth records were successfully matched with and then merged with the clinical discharge records for each newborn collected by the Pennsylvania Health Care Cost Containment Council (PHC4) through a matching procedure using date of birth, gender, subject reported race and ethnicity, zip code, death status, hospital, gestation, and birth weight as variables in the absence of a social security number. To exclude those newborns not
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typically cared for in a ‘‘well baby’’ newborn nursery, the only records selected for analysis were those with diagnosis-related groups (DRG) 391 (normal newborn) and 388 (preterm newborn without major problems) at discharge. Those newborns with hospital charges greater than $8,000 ([98th %ile) and those with MediQual severity of illness ratings that were not ‘‘None’’ were excluded because they were unlikely to represent the typical newborn nursery population. MediQual is a quality and performance analytical system required for all Pennsylvania hospitals that is used to report risk adjusted outcomes [17]. Additionally, newborns with significant problems that could result in a complicated, prolonged, or atypical newborn nursery stay such as respiratory distress syndrome, meconium aspiration syndrome, seizures, central nervous system anomalies, heart malformations, Downs syndrome, and other chromosomal anomalies were excluded as has been done in previous studies [18–24]. Of the remaining records, only those with maternal self-reported race and ethnicity were selected for further analysis resulting in a cohort of 374,649 mother/newborn pairs (89.4% of those with merged PDOH/PHC4 records). 44,105 (11.8%) selfreported that their race and ethnicity was non-Hispanic Black, and this sub-group was matched 1:2 with those selfreporting themselves to be non-Hispanic White for the subsequent analyses. The Human Subjects Protection Office of the Penn State University College of Medicine approved this study. Outcomes The merged datasets from PDOH and PHC4 contained an extensive set of variables related to maternal health status and hospitalization, newborn health status and hospitalization, and socioeconomic variables. Data from the prenatal period included timing and number of prenatal care visits, pregnancy weight gain, tobacco and alcohol use, and pregnancy complications including conditions such as hypertension, pregnancy-induced hypertension, and diabetes. Maternity and newborn hospital data included information on delivery type and complications, length of stay (LOS) in hours since delivery, infant birth weight, sex, gestational age, Apgar scores, and neonatal complications. Socioeconomic data and maternal characteristics included maternal race, ethnicity, age, parity, education, marital status, and insurance type. Information on newborn feeding type was not available. Statistical Analyses Perinatal data from mothers self-classified as non-Hispanic black on the Pennsylvania Certificate of Live Birth and
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data on their infants were compared with data from mothers who reported that they were non-Hispanic white and their infants. To determine what variables are associated with differences between black and white mothers, a bivariate analysis was conducted on the previously mentioned list of maternal and infant characteristics of interest from the matched data. Categorical variables were summarized with frequencies and percentages, and their associations with mother’s race were tested with chi-square tests and odds ratios. Two-sample t-tests with means and 95% confidence intervals were used to test for differences in continuous variables in terms of mother’s race. Where possible, odds ratios with 95% confidence intervals or means with 95% confidence intervals are reported. A mixed model regression analysis was then performed with hospital LOS as the outcome and mother’s race as the primary independent variable. Based on the results of our bivariate analysis and an analysis of associations of the same set of maternal and infant characteristics with LOS, a statistically and/or clinically significant set of covariates and first-order interactions between covariates and mother’s race was included in the model to adjust for unwanted variation that they may account for in the main comparison of mother’s race in terms of hospital LOS. Goodness of fit statistics were used to assess the fit of the model in the presence and absence of each covariate and interaction in determining the final model.
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compared with 76.7% of white mothers (OR 0.11; 95% CL 0.10–0.11). Black mothers were also significantly less likely to have 4 or more years of college (OR 0.25; 95% CL 0.24–0.26), and were more likely to have Medicaid (OR 5.09; 95% CL 4.96–5.22) or be uninsured (OR 2.56; 95% CL 2.37–2.76) as opposed to having private insurance. Black mothers were significantly less likely than white mothers to have prenatal care beginning in the first trimester (OR 0.31; 95% CL 0.30–0.32), but were significantly more likely to have chronic hypertension, to use alcohol, and have pregnancy weight gain at both extremes of the spectrum compared to more normal patterns of weight gain. In contrast, maternal smoking, diabetes (chronic or gestational), and pregnancy-induced hypertension were less common among black than among white mothers.
Delivery History Infants born to black mothers were less likely to be delivered via Cesarean section (OR 0.82; 95% CL 0.79– 0.84) or assisted vaginal delivery (OR 0.61; 95% CL 0.58– 0.64) and more likely to be born on a weekend (OR 1.22; 95% CL 1.18–1.25). Infant Characteristics
Results Maternal Characteristics Among the eligible subjects, 44,105 (11.8%) newborns in Pennsylvania between 1998 and 2002 were born to nonHispanic black mothers. Table 1 presents comparisons of perinatal characteristics of black and white mothers in the study. Frequency distributions or percentages are shown for blacks in the first column and for whites in the second column. The third column presents black/white crude odds ratios, calculated with regard to the indicated reference category in cases where there are multiple categories. For example, compared with 25–29 year olds, those under age 20 were 3.77 times more likely to be black than to be white. For the entire cohort, black mothers were significantly younger than non-Hispanic white mothers with a mean age at delivery of 25.0 years compared with 28.6 years for white mothers (P \ 0.001). The percentage born to teen mothers (\20 years of age) was higher for black mothers (21.0%) compared with white mothers (6.9%; odds ratio (OR) 3.58; 95% confidence limit (CL) 3.46–3.71). Differences in marital status also existed with 25.8% of black mothers reported being married as
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The mean birth weight for infants 35 weeks gestational age born to black mothers was 3252 g. This was significantly lower than the infants born to white mothers whose mean weight was 3454 g (P \ 0.001). Similarly, infants of black mothers were more likely to have low birth weight \2500 g (OR 2.36; 95% CL 2.21–2.51) and they were more likely to be born between 35 weeks and 36 weeks (OR 1.80; 95% CL 1.71–1.90) and 37 and 38 weeks gestation (OR 1.27; 95% CL 1.24–1.31) as opposed to 39 or 40 weeks gestation. Mean nursery LOS was significantly longer for infants born to black mothers (55.0 h vs. 51.5 h; P \ 0.001) despite the fact that there were fewer Cesarean sections. Short nursery stays \48 h were also less likely to occur for infants born to black mothers (P \ 0.001). Black newborns had longer nursery stays after unassisted and assisted vaginal deliveries as well as Cesarean sections with and without stratification for gestational age (Table 2). Multivariate Analysis of Length of Stay Race differences in terms of LOS remained statistically significant in a multivariable model even after adjusting for
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Table 1 Comparison of perinatal variables between non-Hispanic Blacks and non-Hispanic Whites Black* N = 44,105 (%)
White* N = 88,210 (%)
Crude odds ratio
P
\20
9,244 (21.0)
6,088 (6.9)
3.77 (3.62–3.92)
\0.001
20–24
14,035 (31.8)
16,736 (19.0)
2.08 (2.01–2.15)
25–29
10,059 (22.8)
24,952 (28.3)
1.00 (ref)
30–34
6,777 (15.4)
26,227 (29.8)
0.64 (0.62–0.66)
35–39
3,273 (7.4)
11,979 (13.6)
0.68 (0.65–0.71)
40
701 (1.6)
2,170 (2.5)
0.80 (0.73–0.88)
Married to newborn’s father
11,369 (25.8)
67,683 (76.7)
0.11 (0.10–0.11)
\0.001
Primiparous
16,634 (37.9)
35,531 (40.4)
0.90 (0.88–0.92)
\0.001 \0.001
Maternal characterisitics Age in years
Education High school graduate or less
26,914 (64.0)
37,761 (43.5)
1.00 (ref)
Some college
9,876 (23.5)
19,623 (22.6)
0.71 (0.69–0.73)
4 years college
5,252 (12.5)
29,485 (33.9)
0.25 (0.24–0.26)
Insurance type Private
17,607 (41.8)
66,463 (77.4)
1.00 (ref)
Medicaid
23,112 (54.8)
17,149 (20.0)
5.09 (4.96–5.22)
Uninsured
1,138 (2.7)
1,681 (2.0)
2.56 (2.37–2.76)
Other
293 (0.7)
560 (0.7)
1.98 (1.71–2.28)
\0.001
Pregnancy History Trimester began prenatal care 1st trimester
30,482 (74.0)
76,898 (90.2)
1.00 (ref)
2nd trimester
8,126 (19.7)
6,814 (8.0)
3.01 (2.91–3.12)
3rd trimester
1,890 (4.6)
1,265 (1.5)
3.77 (3.51–4.05)
No prenatal care
669 (1.6)
324 (0.4)
5.21 (4.56–5.95)
\0.001
Diabetes
1,011 (2.3)
2,695 (3.1)
0.75 (0.69–0.80)
\0.001
Chronic hypertension Pregnancy-induced hypertension
636 (1.4) 1,527 (3.5)
649 (0.7) 3,313 (3.8)
1.97 (1.77–2.20) 0.92 (0.86–0.98)
\0.001 0.008
Tobacco use during pregnancy
6,758 (15.6)
15,344 (17.5)
0.87 (0.84–0.90)
\0.001
Alcohol use during pregnancy
757 (1.7)
1,120 (1.3)
1.37 (1.25–1.50)
\0.001 \0.001
Pregnancy weight gain in pounds 0–19
7,461 (21.1)
12,425 (15.1)
1.55 (1.50–1.60)
20–39
19,312 (54.6)
49,823 (60.4)
1.00 (ref)
40
8,587 (24.3)
20,179 (24.5)
1.10 (1.07–1.13)
Delivery history Delivery type Unassisted vaginal delivery
33,609 (76.8)
62,723 (71.2)
1.00 (ref)
Assisted vaginal delivery
2,800 (6.4)
8,568 (9.7)
0.61 (0.58–0.64)
Cesarean section delivery
7,349 (16.8)
16,763 (19.0)
0.82 (0.79–0.84)
Weekday (Monday–Friday)
33,291 (75.5)
69,621 (78.9)
1.00 (ref)
Weekend (Saturday–Sunday) Infant Characteristics
10,814 (24.5)
18,589 (21.1)
1.22 (1.18–1.25)
Female
21,891 (49.6)
44,028 (49.9)
0.99 (0.97–1.01)
Male
22,214 (50.4)
44,182 (50.1)
1.00 (ref)
\0.001
Day of the week of delivery/birth \0.001
Sex 0.34
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Table 1 continued Black* N = 44,105 (%)
White* N = 88,210 (%)
Crude odds ratio
P
\0.001
Gestational age (weeks) 35–36
2,726 (6.2)
3,293 (3.8)
1.80 (1.71–1.90)
37–38
11,581 (26.5)
19,746 (22.5)
1.27 (1.24–1.31)
39–40
24,235 (55.4)
52,618 (60.0)
1.00 (ref)
41
5,232 (12.0)
12,103 (13.8)
0.94 (0.91–0.97)
Birth weight in grams \2500
2,153 (4.9)
1,880 (2.1)
2.09 (1.96–2.23)
2500–2999
10,616 (24.1)
12,173 (13.8)
1.59 (1.54–1.64)
3000–3499
18,762 (42.5)
34,218 (38.8)
1.00 (ref)
3500–3999
10,170 (23.1)
29,675 (33.6)
0.63 (0.61–0.64)
4000–4499
2,130 (4.8)
8,738 (9.9)
0.45 (0.42–0.47)
4500
272 (0.6)
1,525 (1.7)
0.33 (0.29–0.37)
Day of the week of discharge Weekday (Monday–Friday) Weekend (Saturday–Sunday)
\0.001
\0.001
30,783 (69.8)
60,675 (68.8)
1.00 (ref)
13,322 (30.2)
27,535 (31.2)
0.95 (0.93–0.98)
Nursery length of stay in hours \24
105 (0.3)
761 (0.9)
0.23 (0.19–0.28)
24–\48
15,204 (35.8)
40,477 (46.1)
0.63 (0.61–0.65)
48–\72
21,207 (49.9)
35,557 (40.5)
1.00 (ref)
72–\96
4,172 (9.8)
8,532 (9.7)
0.82 (0.79–0.85)
96
1,842 (4.3)
2,467 (2.8)
1.26 (1.18–1.33)
\0.001
*Totals of subcategories may not equal the N of the entire cohort due to missing data
Table 2 Comparison of nursery length of stay (LOS) between blacks and non-blacks stratified by delivery type and gestational age Gestational age (weeks)
Unassisted vaginal delivery Black White Mean LOS in hours
Assisted vaginal delivery P
Black White Mean LOS in hours
Cesarean section delivery P
Black White Mean LOS in hours
P
35–36
53.6
52.2
0.02
50.0
52.4
0.16
83.8
79.8
0.008
37–38
50.0
45.9
\0.001
49.5
48.1
0.01
80.2
74.7
\0.001
39–40 41
49.4 49.6
45.4 45.2
\0.001 \0.001
49.9 50.2
47.2 47.2
\0.001 \0.001
80.1 79.6
74.7 74.5
\0.001 \0.001
All
49.9
45.7
\0.001
49.8
47.5
\0.001
80.3
74.9
\0.001
numerous maternal and neonatal covariates that are also associated with mother’s race and LOS (Table 3). After adjusting for the covariates and first-order interactions between the covariates and mother’s race, the mean LOS for newborns of black mothers was still significantly longer than the mean LOS for newborns of white mothers by 4.7 h (P \ 0.001). Maternal covariates left in the model and significantly associated with a longer stay were health insurance, higher education, not married, primiparity, pregnancy-induced hypertension, and non-smoking. Delivery and infant covariates significantly associated with a longer stay were Cesarean section delivery, low birth weight, young gestational age at birth, male sex, weekend
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birth, weekday discharge, and no prenatal care. Variables not significantly associated with LOS in the final model were chronic hypertension, diabetes, and age. Significant interactions existed between race and delivery type, gestational age, birth weight, age, insurance type, education, parity, prenatal care, and marital status (all with P \ 0.001). Multivariate analyses for LOS were also conducted after stratifying for delivery type. For unassisted and assisted vaginal deliveries, race remained highly significant (P \ 0.001 for both) with Black newborns having longer stays. However, for Cesarean deliveries, though Black newborns had a longer mean LOS, race was not
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Table 3 Results of multivariate linear regression modeling length of stay P Maternal Characteristics Age
0.47
Black race versus White racea
\0.001
Insurance typeb
\0.001
Educationc
\0.001
Not married versus married
\0.001
Primiparity versus Multiparity Pregnancy history
\0.001
Pregnancy-induced hypertension versus none
\0.001
Chronic hypertension versus one
0.07
Diabetes versus None
0.21
No prenatal care versus prenatal care
\0.001
No tobacco use versus tobacco use
\0.001
Delivery history Cesarean delivery versus vaginal delivery
\0.001
Weekend delivery/birth versus Weekday delivery/birth
0.035
Infant characteristics Birth weight \2500 g versus Birth weight 2500 g
\0.001
Young gestational age at birthd
\0.001
Male sex versus female sex
\0.001
Weekday discharge versus Weekend discharge
\0.001
a
Significant interactions existed between Race and delivery type, Gestational age, Birth weight, Age, Insurance type, Education, Parity, Prenatal care, and Marital status (all with P \ 0.001)
b
Longest to shortest: Private Insurance, Medicaid, Other, Uninsured
c
Longest to shortest: 4 years of college, Some college, High School Education or less d
Longest to shortest: 35–36 weeks, 37–38 weeks, 39–40 weeks, 41 weeks
statistically (P = 0.34).
significant
in
the
multivariate
model
Discussion The findings of this study represent perhaps the most comprehensive examination to date of perinatal racial disparities among newborns cared for in well-baby nurseries and their mothers. The results demonstrate numerous substantial perinatal disparities among non-Hispanic black mothers and their newborns when compared with nonHispanic whites. While much of the literature on disparities focuses on preterm newborns and their mothers, examining differences in the normal nursery population is also important because this is the care setting experienced by the vast majority of black mothers and their newborns, and the disparities described impact their health and healthcare before and after delivery.
Consistent with other reports and national data, black mothers in Pennsylvania were younger and more likely to give birth during adolescence [7, 25]. Though the national rate of teen pregnancy is declining at the fastest rate for non-Hispanic blacks, the current data suggests that the gap remains wide as 21% of the newborns from the black population were to adolescent mothers compared with 7% in the white population. Though adverse pregnancy outcomes such as low birth weight and preterm birth are not the focus of this report, it is notable that younger maternal age is associated with an increased risk of these outcomes [26] Also, the younger age of the mothers likely contributes to the fact that black mothers are less likely to have completed college at the time of birth and are less likely to be married. These data show that black mothers were far less likely to be married (76.9% married at the time of delivery for white mothers versus 25.8% for black mothers), and this striking difference requires discussion. Limited attention has been paid to this disparity in the medical literature [7], which in part is likely due to the younger maternal age at delivery. It also is somewhat explained by the increased likelihood of cohabitation without marriage in the black population [27]. In such a relationship, a two parent family union raises children together in a home outside of marriage, but compared with married women, cohabitating women are more likely to be depressed, be victims of domestic violence, and have infants that are born preterm or low birth weight [28–30]. As part of The National Survey of Family Growth (NSFG), it was shown that black women were 69% more likely to conceive a child in a cohabitating relationship than white women [27]. The majority of the pregnancies in the NSFG were intended, and it is possible that being unmarried has the financial benefit of remaining welfare and Medicaid-eligible for lower income women [31–33]. Data offering alternative explanations are limited, but particularly for a state whose former U.S. senator published a book entitled, ‘‘It Takes a Family,’’ the remarkably disparate findings require further exploration to understand the reasons behind them and their relation to cultural norms [34]. Consistent with other reports, the current data from Pennsylvania indicate that black women are significantly more likely to have later onset of prenatal care than white women [7, 12–15]. Though black women may be less likely to report barriers to prenatal care [35], the psychosocial and structural barriers that do exist may account for the disparities in initiation of prenatal care that are seen in our analyses. Structural barriers that have been reported by black women include transportation difficulties, long waits at clinics, and inability to get an appointment in a timely fashion [36]. Among the psychosocial barriers that have been reported by black women are having too many other
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problems, having no problems in a previous pregnancy, being afraid of the medical exam or of substance use discovery, consideration of abortion, and previous abortion experience [36, 37]. Later onset of prenatal care can lead to diminished maternal and fetal monitoring and therefore a lack of detection of maternal and/or fetal problems during pregnancy. Additionally, with later onset of care there are fewer opportunities for healthy lifestyle counseling which could contribute to the birth weight differences detected in the current data [38–43]. Also notable, late onset of prenatal care has also been associated with decreased postpartum preventive health care for mothers and insufficient preventive care for their infants [44–48]. As for delivery outcomes, racial differences in Cesarean section rates have been described previously [49, 50]. Much of the difference has been related to lower socioeconomic status rather than race, and many of the operative deliveries particularly in white women could be judged as unnecessary. Either way, the absence of a biological explanation for this disparity leaves a difference that could be disadvantageous to one group. Despite the lower rate of Cesarean sections found in Pennsylvania, black women were more likely to deliver newborns earlier than 37 or 39 weeks gestation and at lower birth weights than white women, results that also have been reported elsewhere [15, 51, 52]. The findings reported by this analysis have several limitations, which limit its generalizability. First, these data describe the disparities between mothers and their ‘‘well’’ newborns 35 weeks gestation only in Pennsylvania. It is possible that states with different racial, urban/rural, and insurance compositions could have different results, but it is probable that similar findings would be found elsewhere in the U.S. based on the similarities between some of the current data presented and those from national reports. A second limitation relates to how race was reported for this analysis since multiple races were not reported prior to 2003, and this is now possible under the guidance of the U.S. Standard Certificate of Live Birth. Thirdly, nearly 20% of newborns did not have birth records that could be matched to and merged with a clinical discharge record. It is probable that this occurred more frequently for black mother/baby pairs because matching success was less likely in more highly populated zip codes, which tend to have a relatively larger black population. Fourth, though the intent of this analysis was to study the majority of mother/newborn pairs that do not include those with major neonatal morbidity, the exclusion criteria involving premature delivery and major neonatal morbidity do limit the ability to describe disparities between all black mothers and their newborns. Fifth, this report describes perinatal data from 1998 to 2002, and the perinatal care environment is constantly evolving. That noted, there have been no
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major legislative or medical policy changes affecting the maternity or newborn hospitalization since 1996 meaning that the general care model has not changed substantially. Finally, this study contains no information about the postnatal and postpartum care that the mother/baby pairs received, which has the potential to affect, positively or negatively, the health and well being of new families. Despite the limitations of this report, clear perinatal disparities are apparent for black mothers and their well newborns in this sample, and clinicians caring for them could improve their care by recognizing that such differences exist on a population level. The current data provide perhaps the most detailed description to date of a large population of black mothers and their newborns who are cared for on normal maternity wards and well baby nurseries. These data also provide valuable insight into the numerous and often large differences between them and the white population of mothers and their newborns. It has been written that the day-to-day lives of black Americans differ in many respects from the lives of whites [53], and that their perception that national institutions serve them poorly extend to the healthcare system and access to that system. To improve this perception and health disparities for blacks it has been suggested that the three modifiable factors that would lead to improved health care for this minority population would be poverty, uninsurance, and having a primary medical home [54]. All three certainly affect perinatal disparities and the health of mothers and their newborns. Several federal initiatives have been established to address these issues including the Minority Health and Health Disparities Research and Education Act of 2000 and the Closing the Health Gap campaign of the U.S. Department of Health and Human Services [55], but correction of these modifiable factors would clearly require a monumental federal commitment. For healthcare providers and health systems, the American College of Physicians has made suggestions to improve healthcare disparities including the provision of culturally competent care, improved communication with patients, involvement of communities in healthcare activities to integrate cultural beliefs and perspectives into care, and diversifying the workforce of healthcare providers [3]. These recommendations, if implemented, could clearly reduce the disparities presented here and improve the health and healthcare for black mothers and their newborns. Acknowledgements Dr. Paul is supported by grant R40 MC 06630 from the Maternal Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services. A Penn State College of Medicine Dean’s Feasibility Grant as well as a grant from the Children’s Miracle Network awarded to Dr. Paul also supported this work. Co-author, Erik Lehman, MS, had full access to all of the data in the study and
Matern Child Health J (2008) 12:452–460 takes responsibility for the integrity of the data and the accuracy of the data analysis. The authors thank Maxine Vance and Rosalind German for their review and editorial comments, and Edward Hain from the Pennsylvania Healthcare Cost Containment Council (PHC4) for his extensive technical assistance. Additional assistance was provided by Craig Edelman from the Pennsylvania Department of Health. PHC4, who provided the clinical discharge records, is an independent state agency responsible for addressing the problem of escalating health costs, ensuring the quality of healthcare, and increasing access to health care for all citizens regardless of ability to pay. PHC4 provided their data in an effort to further PHC4’s mission of educating the public and containing health care costs in Pennsylvania. PHC4, its agents, and staff, have made no representation, guarantee, or warranty, express or implied, that the data: financial, patient, payor, and physician specific information provided to this entity, are error-free, or that the use of the data will avoid differences of opinion or interpretation. The authors of this manuscript conducted this analysis without the assistance of PHC4, which bears no responsibility or liability for the results of the analysis.
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15.
16.
17. 18.
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