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Gaps in NICU Care Put Black Infants at Risk

Gaps in NICU Care Put Black Infants at Risk

Racial disparities in perinatal care persist in neonatal intensive care units (NICUs), according to a qualitative review. Across 41 studies, African-American women tended to give birth in lower-ranked hospitals and less often experienced timely transplants or other early interventions when they had high-risk infants, reported Krista Sigurdson, PhD, of Stanford University in Stanford, California, and colleagues. Hospitals serving mostly minority populations also had higher infant mortality rates and a greater patient-to-nurse ratio, they wrote in Pediatrics . “We did find differences between hospitals but also within hospitals, so essentially there is pretty ample evidence: In most of the studies, minority populations fare worse when compared to white populations,” co-author Jochen Profit, MD, MPH of Stanford University, told MedPage Today . A recent American Academy of Pediatrics policy statement recommends that physicians improve communication with families to move towards “culturally competent care,” and collaborate with implicit bias training programs to reduce differences in care. “While progress has been made toward racial equality, the impact of racism on communities of color is wide-reaching, systemic and complex,” said Maria Trent, MD, MPH, of John Hopkins Medicine, and lead author of the policy statement, in a press release . “A combination of strategies will be needed to begin untangling the thread of racism throughout the fabric of our society, and to improve the health of all children.” Black or African-American women experience higher rates of low-birth rate, preterm birth, and infant mortality than other women in the U.S., according to a 2018 March of Dimes report . There have been qualitative analyses of neglectful or judgmental care in the NICU, as well as systemic barriers to care. However, that research suggested that while certain families may be subject to disparate care in the NICU, the infants themselves were not the “targets.” Profit emphasized he does not think the NICU disparities in this review are the result of a provider intentionally prioritizing one infant over another. Instead, they may be a product of institutionalized racism, socioeconomic disparities, or suboptimal communication between parents and providers. He added that there is emerging evidence on the effects of chronic stress caused by racism on pregnancy outcomes like preterm birth. That makes it particularly important to strive for delivering equitable care in the NICU, he said. “A lot of these babies are born already with a disadvantage,” Profit said. “We feel once the baby is requiring intensive care, we shouldn’t let that disparity grow any wider, and ideally we would work towards making it smaller.” The findings presented here are “not surprising” and are also reflected in the execution of maternal care, wrote Wanda Barfield, MD, of the CDC, and colleagues, in an accompanying editorial . “For many, it has been assumed that care in the NICU is consistently of high quality and is delivered equitably,” the editorialists wrote. “[These] researchers challenge the long-held assumption that NICU care is the great equalizer for improving infant health.” To address this, the editorialists recommended improving how to identify the type and quality of care required by NICU infants, ensuring referral plans or perinatal regionalization are implemented so infants receive care in settings that best suit their needs, and promoting further research to determine what is behind these disparities. They also noted the importance of dispelling “myths” of inherent advantages experienced by African-American premature infants. “The perception that an individual infant may have an advantage of survival on the basis of population measures does a disservice to that individual patient and may bias the care delivered,” Barfield and colleagues wrote. Profit said an effective method to reduce these disparities would be implementing quality improvement measures that create standardized care processes for treatment throughout pregnancy, birth, NICU stays, and postpartum recovery. “The idea is, if we can use quality improvement methods to standardize hospital protocol for all populations, we don’t even need to rely on whether a certain healthcare provider has a certain bias or not,” Profit said. Indeed, the authors noted that African-American mothers tended to receive less breastfeeding guidance throughout all stages of pregnancy compared to other mothers. For the analysis, the authors searched for English-language studies that reported the use of appropriate interventions, mortality, access to health care services, and patient evaluations or other direct observations of neonatal intensive care units. In total, 12 articles examined the structure of health systems such as nursing staff, setting, or geography; 19 assessed NICU processes like breast milk use, follow-up referrals, or instances of surfactant and respiratory distress syndrome; and 11 looked at specific outcomes, including intraventricular hemorrhage, necrotizing enterocolitis, and overall mortality and morbidity. They emphasized that it is difficult to disentangle whether the disparities that were revealed in this report were due to the quality of neonatal care, maternal comorbidities, or socioeconomic factors. They also said that some articles were excluded due to language or full-text availability, which may limit the generalizability of the findings. Sigurdson, Profit, and two co-authors were supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Sigurdson was supported by the Stanford Maternal and Child Health Research Institute, funded by the NIH. The editorialists did not report any relevant disclosures. last updated 07.30.2019

Gaps in NICU Care Put Black Infants at Risk

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