Neighborhood Inequality and Emergency Department Use in Neonatal Intensive Care Unit Graduates

Associations between Parental Engagement in the Neonatal Intensive Care Unit and Neighborhood-Level Socioeconomic Status

OBJECTIVE

 This study aimed to (1) determine the effect of neighborhood-level socioeconomic status (SES), which considers the social and physical environment where a person lives, on parental engagement in the Neonatal Intensive Care Unit (NICU) and (2) compare the relationships between parental engagement and individual versus neighborhood-level measures of SES.

STUDY DESIGN

 In this cohort study, parents (n = 45) of premature neonates ≤34 weeks' gestation were assessed at 2 and 6 weeks after birth from December 2017 to October 2019. Neighborhood-level SES was determined using census data per the Association of Maternal and Child Health Programs' methodology, and parents self-reported their education level as an individual-level measure of SES. Data on frequency of engagement in NICU activities, including telephone updates, visitation, providing expressed breastmilk, and participating in kangaroo care, were collected from the electronic medical record. Parent psychosocial factors were assessed using validated surveys. Statistical analysis was performed using Fisher's exact test, t-test, and logistic regression.

RESULTS

 In multivariate regression analysis, disadvantaged neighborhood-level SES was associated with decreased odds of kangaroo care (OR = 0.16, 95% CI: [0.03-0.89]) and visitation (OR = 0.14, 95% CI: [0.02-0.87]), while lower individual-level SES was not significantly associated with kangaroo care, visiting, calling, or pumping (p > 0.05).

CONCLUSION

 Parental engagement was more consistently and significantly associated with neighborhood-level SES than with individual-level SES. Therefore, neighborhood-level SES measures may be more explanatory than individual-level SES measures. Further studies and targeted interventions are needed to address disparities in the frequency of kangaroo care and visitation according to SES.

KEY POINTS

· Parents from disadvantaged neighborhoods are less likely to do kangaroo care and visit the NICU.. · Parent engagement was more significantly associated with neighborhood than with parent education.. · Neighborhood-level SES measures may be more explanatory than individual-level SES measures.. · Interventions are needed to address SES-related disparities in NICU kangaroo care and visitation..

Neighborhood risk and prenatal care utilization in Rhode Island, 2005-2014

BACKGROUND

The importance of prenatal care is undeniable, as pregnant persons who receive on-time, adequate prenatal care have better maternal and infant health outcomes compared with those receiving late, less than adequate prenatal care. Previous studies assessing the relationship between neighborhood factors and maternal health outcomes have typically looked at singular neighborhood variables and their relationship with maternal health outcomes. In order to examine a greater number of place-based risk factors simultaneously, our analysis used a unique neighborhood risk index to assess the association between cumulative risk and prenatal care utilization, which no other studies have done.

METHODS

Data from Rhode Island Vital Statistics for births between 2005 and 2014 were used to assess the relationship between neighborhood risk and prenatal care utilization using two established indices. We assessed neighborhood risk with an index composed of eight socioeconomic block-group variables. A multivariate logistic regression model was used to examine the association between adequate use and neighborhood risk.

RESULTS

Individuals living in a high-risk neighborhood were less likely to have adequate or better prenatal care utilization according to both the APNCU Index (adjusted odds ratio [aOR] 0.91, 95% confidence interval [CI] 0.87-0.95) and the R-GINDEX (aOR 0.88, 95% CI 0.85-0.91) compared with those in low-risk neighborhoods.

CONCLUSION

Understanding the impact of neighborhood-level factors on prenatal care use is a critical first step in ensuring that underserved neighborhoods are prioritized in interventions aimed at making access to prenatal care more equitable.

Improving Postpartum Depression Screening in the NICU: Partnering with Students to Improve Outreach

Infants born to mothers with postpartum depression (PPD) are at risk for adverse developmental outcomes. Mothers of premature infants are 40% more likely to develop PPD when compared with the general population. Current published studies on implementing PPD screening in the Neonatal Intensive Care Unit (NICU) do not comply with the American Academy of Pediatrics (AAP) guideline, which recommends multiple screening points in the first year postpartum and includes partner screening. Our team implemented PPD screening that follows the AAP guideline and includes partner screening for all parents of infants admitted to our NICU beyond 2 weeks of age.

Methods

The Institute For Healthcare Improvement Model for Improvement was the framework for this project. Our initial intervention bundle included provider education, standardized identification of parents to be screened, and bedside screening performed by the nurse with social work follow-up. This intervention transitioned to weekly screening by phone by health professional students and the use of the electronic medical record for notification of team members of screening results.

Results

Under the current process, 53% of qualifying parents are screened appropriately. Of the parents screened, 23% had a positive Patient Health Questionnaire-9 requiring referral for mental health services.

Conclusions

Implementing a PPD screening program that complies with the AAP standard is feasible within a Level 4 NICU. Partnering with health professional students greatly improved our ability to screen parents consistently. Given the high percentage of parents with PPD uncovered with appropriate screening, this type of program has a clear need within the NICU.

Outcomes of Preterm Infants: Shifting Focus, Extending the View

Advances in perinatal care have led to remarkable long-term survival for infants who are born preterm. This article reviews the broader context of follow-up care, highlighting the need to reenvision some areas, such as improving parental support by embedding parental involvement in the neonatal intensive care unit, incorporating parental perspectives about outcomes into follow-up care models and research, supporting their mental health, addressing social determinants of health and disparities, and advocating for change. Multicenter quality improvement networks allow identification and implementation of best practices for follow-up care.

Structural racism is associated with adverse postnatal outcomes among Black preterm infants

BACKGROUND

Structural racism contributes to racial disparities in adverse perinatal outcomes. We sought to determine if structural racism is associated with adverse outcomes among Black preterm infants postnatally.

METHODS

Observational cohort study of 13,321 Black birthing people who delivered preterm (gestational age 22-36 weeks) in California in 2011-2017 using a statewide birth cohort database and the American Community Survey. Racial and income segregation was quantified by the Index of Concentration at the Extremes (ICE) scores. Multivariable generalized estimating equations regression models were fit to test the association between ICE scores and adverse postnatal outcomes: frequent acute care visits, readmissions, and pre- and post-discharge death, adjusting for infant and birthing person characteristics and social factors.

RESULTS

Black birthing people who delivered preterm in the least privileged ICE tertiles were more likely to have infants who experienced frequent acute care visits (crude risk ratio [cRR] 1.3 95% CI 1.2-1.4), readmissions (cRR 1.1 95% CI 1.0-1.2), and post-discharge death (cRR 1.9 95% CI 1.2-3.1) in their first year compared to those in the privileged tertile. Results did not differ significantly after adjusting for infant or birthing person characteristics.

CONCLUSION

Structural racism contributes to adverse outcomes for Black preterm infants after hospital discharge.

IMPACT STATEMENT

Structural racism, measured by racial and income segregation, was associated with adverse postnatal outcomes among Black preterm infants including frequent acute care visits, rehospitalizations, and death after hospital discharge. This study extends our understanding of the impact of structural racism on the health of Black preterm infants beyond the perinatal period and provides reinforcement to the concept of structural racism contributing to racial disparities in poor postnatal outcomes for preterm infants. Identifying structural racism as a primary cause of racial disparities in the postnatal period is necessary to prioritize and implement appropriate structural interventions to improve outcomes.

Racial and Economic Neighborhood Segregation, Site of Delivery, and Morbidity and Mortality in Neonates Born Very Preterm

OBJECTIVE

To assess the influence of racial and economic residential segregation of home or hospital neighborhood on very preterm birth morbidity and mortality in neonates born very preterm.

STUDY DESIGN

We constructed a retrospective cohort of n = 6461 infants born <32 weeks using 2010-2014 New York City vital statistics-hospital data. We calculated racial and economic Index of Concentration at the Extremes for home and hospital neighborhoods. Neonatal mortality and morbidity was defined as death and/or severe neonatal morbidity. We estimated relative risks for Index of Concentration at the Extremes measures and neonatal mortality and morbidity using log binomial regression and the risk-adjusted contribution of delivery hospital using Fairlie decomposition.

RESULTS

Infants whose mothers live in neighborhoods with the greatest relative concentration of Black residents had a 1.6 times greater risk of neonatal mortality and morbidity than those with the greatest relative concentration of White residents (95% CI 1.2-2.1). Delivery hospital explained more than one-half of neighborhood differences. Infants with both home and hospital in high-concentration Black neighborhoods had a 38% adjusted risk of neonatal mortality and morbidity compared with 25% of those with both home and hospital high-concentration White neighborhoods (P = .045).

CONCLUSIONS

Structural racism influences very preterm birth neonatal mortality and morbidity through both the home and hospital neighborhood. Quality improvement interventions should incorporate a framework that includes neighborhood context.

Neighborhood Conditions and Recurrent Emergency Department Utilization by Children in the United States

OBJECTIVE

To determine the associations of social and physical neighborhood conditions with recurrent emergency department (ED) utilization by children in the US.

STUDY DESIGN

This cross-sectional study was conducted with the National Survey of Children's Health from 2016 to 2018 to determine the associations of neighborhood characteristics of cohesion, safety, amenities, and detractors with the proportions of children aged 1-17 years with recurrent ED utilization, defined as 2 or more ED visits during the past 12 months. A multivariable regression model was used to determine the independent association of each neighborhood characteristic with recurrent ED utilization controlling for individual-level characteristics.

RESULTS

In this study of 98 711 children weighted to a population of 70 million nationally, children had significantly greater rates of recurrent ED utilization if they lived in neighborhoods that were not cohesive, were not safe, or had detractors present (all P < .001). With adjustment for individual-level covariates and the other neighborhood characteristics, only neighborhood detractors were independently associated with recurrent ED utilization (1 detractor: aOR 1.32, 95% CI 1.03-1.68; 2 or 3 detractors: aOR 1.37, 95% CI 1.04-1.81).

CONCLUSIONS

Among neighborhood characteristics, the presence of physical detractors such as rundown housing and vandalism was most strongly associated with recurrent ED utilization by children. Negative attributes of the built environment may be a potential target for neighborhood-level, place-based interventions to alleviate disparities in child healthcare utilization.