Validity of infant race/ethnicity from birth certificates in the context of U.S. demographic change

Racial and Ethnic Disparities in Infant Mortality Rates Among Infants Born Preterm in the US Beyond 44 Weeks of Postmenstrual Age

OBJECTIVE

To investigate racial and ethnic disparities in the incidence of infant mortality, timing, and cause of death among infants born preterm in the US who survive to 44 weeks of postmenstrual age (PMA).

STUDY DESIGN

Retrospective cohort analysis using linked national birth and death certificate data from 2005 to 2014. Univariable and multivariable analyses were used to assess the associations between race and ethnicity and mortality rate, and timing of death. Descriptive analysis was used to examine differences in cause of death.

RESULTS

Among 3 979 512 infants born preterm, the mortality rate and adjusted odds of death were greatest for American Indian/Alaskan Native (AI/AN) and Non-Hispanic Black (NHB) infants (aOR 1.62; 95% CI 1.43-1.83 and aOR 1.45; 95% CI 1.40-1.51, respectively) compared with Non-Hispanic White (NHW) infants. In addition, AI/AN and NHB infants experienced divergence in survival rates from 44 to 60 weeks of PMA. Sudden unexpected infant death was the leading cause of death for AI/AN, NHB, and NHW infants born preterm.

CONCLUSIONS

Significant disparities in preterm infant mortality rate at postterm corrected gestational age persist. Further research is needed to examine contributory factors for these racial and ethnic differences in timing and cause of death.

Court-mandated redistricting and disparities in infant mortality and deaths of despair

BACKGROUND

Health and health disparities vary substantially by geography, including geopolitical boundaries such as United States congressional districts. Every ten years congressional districts for the House of Representatives are redistricted, but occasionally the Courts step in and force states to redistrict gerrymandered congressional maps. Analyses of court mandated redistricting decisions often focus on the distribution of voters by political party and race, but less is known about how health and health disparities are distributed across congressional districts before and after redistricting. In this analysis, we examine how the magnitude of disparities varied between and within congressional districts in Pennsylvania, before and after the state Supreme Court of Pennsylvania's decision ordering a redistricting in 2018 that produced less politically gerrymandered districts.

METHODS

Using georeferenced vital statistics data from 2013-2015 (before the redistricting), we explore levels of and disparities in infant mortality rates (IMR) and deaths of despair (DoD) using boundaries from before (Congresses 113-115) and after (Congress 116) this redistricting.

RESULTS

Using consistent mortality data (2013-2015) and boundaries from before and after the 2018 redistricting, we find that after redistricting disparities in infant mortality and deaths of despair between congressional districts were slightly wider for all educational groups except for those with less than a high school degree, and slightly narrower for all racial-ethnic groups other than for Hispanic and non-Hispanic White populations, compared with before redistricting.

CONCLUSIONS

Understanding how disparities vary between and within districts after redistricting can inform our understanding of the relationships between geopolitical boundaries, election processes, and health disparities.

Neonatal mortality among disaggregated Asian American and Native Hawaiian/Pacific Islander populations

OBJECTIVE

We compared neonatal (<28 days) mortality rates (NMRs) across disaggregated Asian American and Native Hawaiian/Pacific Islander (AANHPI) groups using recent, national data.

STUDY DESIGN

We used 2015-2019 cohort-linked birth-infant death records from the National Vital Statistics System. Our sample included 61,703 neonatal deaths among 18,709,743 births across all racial and ethnic groups. We compared unadjusted NMRs across disaggregated AANHPI groups, then compared NMRs adjusting for maternal sociodemographic, maternal clinical, and neonatal risk factors.

RESULTS

Unadjusted NMRs differed by over 3-fold amongst disaggregated AANHPI groups. Native Hawaiian/Pacific Islander neonates in aggregate had the highest fully-adjusted odds of mortality (OR: 1.08 [95% CI: 0.89, 1.31]) compared to non-Hispanic White neonates. Filipino, Asian Indian, and Other Asian neonates experienced significant decreases in odds ratios after adjusting for neonatal risk factors.

CONCLUSION

Aggregating AANHPI neonates masks large heterogeneity and undermines opportunities to provide targeted care to higher-risk groups.

Racial and ethnic disparities in premature births among pregnant women in the NISAMI cohort, Brazil

The incidence of premature birth has increased worldwide, unequally distributed by race/ethnicity. Racism generates economic inequalities, educational disparities, and differential access to health care, which increases the risk of preterm birth. Thus, this study aimed to evaluate the factors associated with preterm birth and racial and ethnic disparities in premature birth among pregnant women attending prenatal care at the Brazilian Unified Health System health units in the urban area of Santo Antônio de Jesus, Bahia, Brazil. This study used data from 938 pregnant women aged between 18 to 45 years within the NISAMI prospective cohort. Premature birth prevalence was 11.8%, with a higher prevalence among black than non-black women (12.9% versus 6.0%, respectively). Maternal age between 18 and 24 years was the only factor associated with premature birth. A higher risk of premature birth was found among black women than non-black women (RR 3.22; 95%CI 1.42-7.32). These results reveal the existence of racial and social inequalities in the occurrence of premature birth.

Improving data capture of race and ethnicity for the Food and Drug Administration Sentinel database: a narrative review

PURPOSE

The U.S. Food and Drug Administration's Sentinel System is a national medical product safety surveillance system consisting of a large multisite distributed database of administrative claims supplemented by electronic health-care record data. The program seeks to improve data capture of race and ethnicity for pharmacoepidemiology studies.

METHODS

We conducted a narrative literature review of published research on data augmentation and imputation methods to improve race and ethnicity capture in U.S. health-care systems databases. We focused on methods with limited (five-digit ZIP codes only) or full patient identifiers available to link to external sources of self-reported data. We organized the literature by themes: (1) variation in data capture of self-reported data, (2) data augmentation from external sources of self-reported data, and (3) imputation methods, including Bayesian analysis and multiple regression.

RESULTS

Researchers reduced data missingness with high validity for Asian, Black, White, and Pacific Islander racial groups and Hispanic ethnicity. Native American and multiracial groups were difficult to validate due to relatively small sample sizes.

CONCLUSIONS

Limitations on accessible self-reported data for validation will dictate methods to improve race and ethnicity data capture. We recommend methods leveraging multiple sources that account for variations in geography, age, and sex.

Defining an Infant's Race and Ethnicity: A Systematic Review

CONTEXT

Infant race and ethnicity are used ubiquitously in research and reporting, though inconsistent approaches to data collection and definitions yield variable results. The consistency of these data has an impact on reported findings and outcomes.

OBJECTIVE

To systematically review and examine concordance among differing race and ethnicity data collection techniques presented in perinatal health care literature.

DATA SOURCES

PubMed, CINAHL, and Ovid were searched on June 17, 2021.

STUDY SELECTION

English language articles published between 1980 and 2021 were included if they reported on the United States' infant population and compared 2 or more methods of capturing race and/or ethnicity.

DATA EXTRACTION

Two authors independently evaluated articles for inclusion and quality, with disagreements resolved by a third reviewer.

RESULTS

Our initial search identified 4329 unique citations. Forty articles passed title/abstract review and were reviewed in full text. Nineteen were considered relevant and assessed for quality and bias, from which 12 studies were ultimately included. Discordance in infant race and ethnicity data were common among multiple data collection methods, including those frequently used in perinatal health outcomes research. Infants of color and those born to racially and/or ethnically discordant parents were the most likely to be misclassified across data sources.

LIMITATIONS

Studies were heterogeneous in methodology and populations of study and data could not be compiled for analysis.

CONCLUSIONS

Racial and ethnic misclassification of infants leads to inaccurate measurement and reporting of infant morbidity and mortality, often underestimating burden in minoritized populations while overestimating it in the non-Hispanic/Latinx white population.

Racial disparities in the development of comorbid conditions after preterm birth: A narrative review

Despite recognition and attempts to reduce racial disparities in perinatal outcomes, Black infants are still disproportionately represented among those who are born preterm. Postnatal investigations of racial disparities in comorbidities and outcomes after preterm birth are increasing, although their results and interpretations are conflicting. In the present review, we 1.) identify important methodological limitations of that literature 2.) summarize the conflicting literature investigating racial disparities, specifically Black-white differences, in postnatal comorbidities and outcomes after preterm birth 3.) describe mechanisms by which racism operates to contextualize our understanding to inform future work to actively reduce disparities in preterm birth and subsequently, its complications.

Perinatal Opioid Use Disorder Research, Race, and Racism: A Scoping Review

CONTEXT

Racial/ethnic inequities are well documented in both maternal-infant health and substance use disorder treatment outcomes.

OBJECTIVE

To systematically review research on maternal-infant dyads affected by opioid use disorder (OUD) to evaluate for racial/ethnic disparities in health utilization or outcomes and critically assess the reporting and inclusion of race/ethnicity data.

DATA SOURCES

Peer-reviewed literature in MEDLINE, Embase, and Web of Science from 2000 to 2020.

STUDY SELECTION

Research reporting health utilization and outcomes data on dyads affected by OUD during pregnancy through the infant's first birthday.

DATA EXTRACTION

We extracted data on race/ethnicity, study exposures/outcomes, how race/ethnicity data were analyzed, how authors discussed findings associated with race/ethnicity, and whether racism was mentioned as an explanation for findings.

RESULTS

Of 2023 articles reviewed, 152 quantitative and 17 qualitative studies were included. Among quantitative studies, 66% examined infant outcomes (n = 101). Three articles explicitly focused on evaluating racial/ethnic differences among dyads. Among quantitative studies, 112 mentioned race/ethnicity, 63 performed analyses assessing for differences between exposure groups, 27 identified racial/ethnic differences, 22 adjusted outcomes for race/ethnicity in multivariable analyses, and 11 presented adjusted models stratified by race/ethnicity. None of the qualitative studies addressed the role that race, ethnicity, or racism may have had on the presented themes.

CONCLUSIONS

Few studies were designed to evaluate racial/ethnic inequities among maternal-infant dyads affected by OUD. Data on race/ethnicity have been poorly reported in this literature. To achieve health equity across perinatal OUD, researchers should prioritize the inclusion of marginalized groups to better address the role that structural racism plays.

Racial and Ethnic Disparities in Perinatal Insurance Coverage

Gaps and transitions (disruptions) in perinatal insurance coverage disproportionately affect indigenous, Hispanic, and black non-Hispanic women.

To measure the association between race–ethnicity and insurance status at preconception, delivery, and postpartum and the frequency of insurance gaps and transitions (disruptions) across these time points.

The Impact of CenteringPregnancy Group Prenatal Care on Birth Outcomes in Medicaid Eligible Women

Background: CenteringPregnancy group prenatal care (GPNC) has been shown to reduce rates of preterm birth (PTB). We evaluated the impact of GPNC on spontaneous PTB (sPTB) as a first step in exploring the possible mechanism by which GPNC may decrease rates of PTB. We also evaluated whether attending more than five GPNC sessions affected PTB risk and examined all differences by race/ethnicity. Materials and Methods: We conducted a retrospective cohort study among women delivering at a single institution between April 2009 and March 2014. Birth outcome data from vital statistics records were appended to patient records, and detailed chart abstraction was used to determine spontaneous versus indicated PTB. The association between GPNC and attending more than five GPNC sessions and birth outcomes (i.e., PTB, sPTB, low birth weight [LBW], and neonatal intensive care unit [NICU] admissions) was analyzed using generalized estimating equation log binomial regression models. We examined effect modification of the associations by race/ethnicity. Results: The analysis included 1,292 women in GPNC and 8,703 in traditional individual prenatal care (IPNC). After controlling for potential confounders, the risk of PTB (risk ratio [RR] 0.38; 95% confidence interval [CI] 0.31-0.47), sPTB (RR 0.49; 95% CI 0.38-0.63), LBW (RR 0.46; 95% CI 0.37-0.56), and NICU admissions (RR 0.46; 95% CI 0.37-0.57) was lower in GPNC compared to IPNC women. Results differed by maternal race/ethnicity, with the strongest associations among non-Hispanic white mothers and the weakest associations among Hispanic mothers, especially for sPTB. Similarly, the risk of PTB, LBW, and NICU admissions was lower among GPNC women who attended more than five sessions. Conclusion: Participation in GPNC demonstrated a decreased risk for sPTB, as well as other adverse birth outcomes. In addition, participation in more than five GPNC sessions demonstrated a decreased risk for adverse birth outcomes. Prospective longitudinal studies are needed to further explore mechanisms associated with these findings.

Assessing the role of maternal race on the prediction of NICU admission by three growth charts: a cross-sectional study

BACKGROUND

The National Institutes of Health (NIH) race-specific and Intergrowth 21st race-independent fetal growth standards have recently been developed to assess fetal growth although the Alexander reference has been commonly used for over two decades. Societies are becoming increasingly stratified by race, and thus fetal growth effects are increasingly socially-derived. Relatedly, there is discussion surrounding the utility of classifying fetal growth on the basis of ideal growth versus typical growth. Therefore, we aimed to evaluate the classification discrepancies for small for gestational age (SGA) or large for gestational age (LGA) infants between growth charts, stratified by maternal race; and to determine which chart most accurately identifies vulnerable infants requiring NICU (Neonatal Intensive Care Unit) admission.

METHODS

This cross-sectional study examined singleton liveborn infants born between 33 and 42 weeks of gestation with a self-identified White, Black, Hispanic, or Asian mother. Data were obtained from the 2014 National Centre of Health Statistics' Vital Statistics Natality files. SGA infants were considered those <10th percentile and LGA were those >90th percentile, for each growth chart. SGA and LGA classification by maternal race was evaluated using stratified analysis and logistic regression. Odds ratios and goodness of fit characteristics were assessed to determine which chart best predicted NICU admission.

RESULTS

In our sample of 3,782,660 singleton infants, significantly different proportions of infants were classified SGA/LGA using the Alexander (SGA: 4.6%, LGA:19.4%), Intergrowth 21st (SGA: 4.0%, LGA:19.6%), and NIH (SGA: 9.8%, LGA: 8.5%) charts. Race-specific classification of SGA differed by race and chart; there was an 8.4% difference in white infants considered SGA by Intergrowth (3.3; 95% CI, 3.2-3.3) compared to NIH (11.7%; 95% CI, 11.6-11.7). The NIH and Intergrowth 21st charts were typically in agreement for both SGA and LGA, differing substantially from the Alexander reference; however, there were significant differences between Intergrowth and NIH for proportions of SGA (NIH: 10.2%, CI 95%, 10.1-10.2; Intergrowth: 4.0%, CI 95%, 3.9-4.0) and LGA (NIH: 6.3%, CI 95%, 6.3-6.4; Intergrowth: 19.6%, CI 95%, 19.5-19.6) infants. Overall, 11.1% of Black infants were considered SGA by NIH and 6.8% by Intergrowth-more often than other races. Intergrowth classified the fewest infants as SGA and Alexander classified the most as SGA for all races. While NIH was better at discriminating LGA (OR: 2.72) and SGA-associated (OR: 1.71) NICU admissions compared to other charts, no standard was a significantly better predictor of NICU admission.

CONCLUSION

Since the NIH standard identified the fewest LGA infants and the Intergrowth 21st standard identified the fewest SGA infants, these charts may have been better identifiers of infants on either extreme of growth. The agreement between NIH and Intergrowth 21st charts suggest their interchangeable use for healthy populations, but the NIH may be more applicable given its racial stratification. However, the differences in proportions of SGA/LGA infants among the three charts according to maternal race introduce significant clinical ambiguity when identifying vulnerable infants. Additionally, no chart was able to accurately identify vulnerable infants and the dataset did not permit differentiation between growth-restricted and constitutionally small infants. Further work is necessary before selecting a true gold standard for use in routine clinical practice.

Imputing race and ethnic information in administrative health data

OBJECTIVE

To improve on existing methods to infer race/ethnicity in health care data through an analysis of birth records from Connecticut.

DATA SOURCE

A total of 162 467 Connecticut birth records from 2009 to 2013.

STUDY DESIGN

We developed a logistic model to predict race/ethnicity using data from US Census and patient-level information. Model performance was tested and compared to previous studies. Five performance measures were used for comparison.

PRINCIPAL FINDINGS

Our full model correctly classifies 81 percent of subjects and shows improvement over extant methods. We achieved substantially improved sensitivity in predicting black race.

CONCLUSIONS

Predictive models using Census information and patients' demographic characteristics can be used to accurately populate race/ethnicity information in health care databases, enhancing opportunities to investigate and address disparities in access to, utilization of, and outcomes of care.

Prevalence and descriptive epidemiology of infantile hypertrophic pyloric stenosis in the United States: A multistate, population-based retrospective study, 1999-2010

BACKGROUND

Antecedents for infantile hypertrophic pyloric stenosis (IHPS) vary across studies; therefore, we conducted a multistate, population-based retrospective study of the prevalence and descriptive epidemiology of IHPS in the United States (US).

METHODS

Data for IHPS cases (n = 29,554) delivered from 1999-2010 and enumerated from 11 US population-based birth defect surveillance programs, along with data for live births (n = 14,707,418) delivered within the same birth period and jurisdictions, were analyzed using Poisson regression to estimate IHPS prevalence per 10,000 live births. Additional data on deliveries from 1999-2005 from seven of these programs were analyzed using multivariable logistic regression to estimate adjusted prevalence ratios (aPR)s and 95% confidence intervals (CI)s for selected infant and parental characteristics.

RESULTS

Overall, IHPS prevalence from 1999-2010 was 20.09 (95% CI = 19.87, 20.32) per 10,000 live births, with statistically significant increases from 2003-2006 and decreases from 2007-2010. Compared to their respective referents, aPRs were higher in magnitude for males, preterm births, and multiple births, but lower for birth weights <2,500 g. The aPRs for all cases increased with decreasing parental age, maternal education, and maternal parity, but decreased for parental race/ethnicity other than non-Hispanic White. Estimates restricted to isolated cases or stratified by infant sex were similar to those for all cases.

CONCLUSIONS

This study covers one of the largest samples and longest temporal period examined for IHPS in the US. Similar to findings reported in Europe, estimates suggest that IHPS prevalence has decreased recently in the US. Additional analyses supported associations with several infant and parental characteristics.

Who tells a mother her baby has died? Communication and staff presence during stillbirth delivery and early infant death

OBJECTIVE

Perinatal loss (stillbirth or early infant death) is often a sudden, unexpected event for families. We evaluated who communicates the loss to the parents and who is there for support at the delivery or death.

STUDY DESIGN

We conducted a mail survey of 900 bereaved and 500 live-birth mothers to assess emotional, physical and reproductive health outcomes.

RESULTS

We had a 44% response rate at 9 months after birth or loss from 377 bereaved mothers and 232 with surviving infants. Bereaved women were less likely to have hospital staff or family members present at delivery. African-American (versus Caucasian) mothers were half as likely to have first heard about their stillbirth from a physician or midwife.

CONCLUSION

This is the first large study documenting who communicates perinatal death to families and who is present for support. Hospitals should be aware that many bereaved families may lack support at critical times.

Identifying areas at risk of low birth weight using spatial epidemiology: A small area surveillance study

OBJECTIVES

To assess the geographic distribution of Low Birth Weight (LBW) in New York State among singleton births using a spatial regression approach in order to identify priority areas for public health actions.

METHODS

LBW was defined as birth weight less than 2500g. Geocoded data from 562,586 birth certificates in New York State (years 2008-2012) were merged with 2010 census data at the tract level. To provide stable estimates and maintain confidentiality, data were aggregated to yield 1268 areas of analysis. LBW prevalence among singleton births was related with area-level behavioral, socioeconomic and demographic characteristics using a Poisson mixed effects spatial error regression model.

RESULTS

Observed low birth weight showed statistically significant auto-correlation in our study area (Moran's I 0.16 p value 0.0005). After over-dispersion correction and accounting for fixed effects for selected social determinants, spatial autocorrelation was fully accounted for (Moran's I-0.007 p value 0.241). The proportion of LBW was higher in areas with larger Hispanic or Black populations and high smoking prevalence. Smoothed maps with predicted prevalence were developed to identify areas at high risk of LBW. Spatial patterns of residual variation were analyzed to identify unique risk factors.

CONCLUSION

Neighborhood racial composition contributes to disparities in LBW prevalence beyond differences in behavioral and socioeconomic factors. Small-area analyses of LBW can identify areas for targeted interventions and display unique local patterns that should be accounted for in prevention strategies.

Prevalence and risk factors for postpartum depression symptoms among women with disabilities

The adverse consequences of postpartum depression on the health of the mother and her child are well documented. However, there is little information on postpartum depression among mothers with disabilities. This study examines the patterns of depression and depressive symptoms before, during and after pregnancy and the association between depression before and during pregnancy and postpartum depression symptomatology (PPD) among women with and without disabilities. Data from the 2009-2011 Rhode Island Pregnancy Risk Assessment Monitoring System (PRAMS) were analyzed in 2013. Almost 30% (28.9%; 95% CI 22.8-35.8) of mothers with disabilities reported often or always feeling down, depressed or sad after childbirth compared to 10% of those without disabilities (95% CI 8.9-11.3). Compared to other women in the study, women with disabilities had a greater likelihood for PPD symptoms (RR 1.6, 95% CI 1.1-2.2) after accounting for sociodemographics, maternal characteristics related to PPD, and depression before and during pregnancy. Adjusting for other covariates, self-reported prenatal diagnosis of depression was not associated with symptoms of PPD and depression during pregnancy was marginally associated with PPD symptomatology for women with disabilities. Women with disabilities are at a greater risk of experiencing symptoms of postpartum depression than other women. Screening for PPD among new mothers with disabilities and timely referral of those with PPD diagnosis are vital to the health of mothers with disabilities and their children.

Paternal race/ethnicity and very low birth weight

BACKGROUND

The purpose was to examine the association between paternal race/ethnicity and very low birth weight stratified by maternal race/ethnicity.

METHODS

Birth data for Tarrant County, Texas 2006-2010 were analyzed. Very low birth weight was dichotomized as yes (<1,500 g) and no (≥1,500 g). Paternal race/ethnicity was categorized as Caucasian, African American, Hispanic, other, and missing. Missing observations (14.7%) were included and served as a proxy for fathers absent during pregnancy. Potential confounders included maternal age, education, and marital status, plurality, previous preterm birth, sexually transmitted disease during pregnancy, smoking during pregnancy, and Kotelchuck Index of prenatal care. Logistic regressions were stratified by maternal race/ethnicity. Odds ratios and 95% confidence intervals were calculated.

RESULTS

Of 145,054 births, 60,156 (41.5%) were Caucasian, 22,306 (15.4%) African American, 54,553 (37.6%) Hispanic, and 8,039 (5.5%) other mothers. There were 2,154 (1.5%) very low birth weights total, with 3.1% for African American mothers and 1.2% for all other race/ethnicities. Among Caucasian mothers, African American paternal race was associated with increased odds of very low birth weight (OR = 1.52; 95% CI:1.08-2.14). Among Hispanic mothers, African American paternal race (OR = 1.66; 95% CI:1.01-2.74) and missing paternal race/ethnicity (OR = 1.65; 95% CI:1.15-2.36) were associated with increased odds of very low birth weight.

CONCLUSIONS

Paternal race/ethnicity is an important predictor of very low birth weight among Caucasian and Hispanic mothers. Future research should consider paternal race/ethnicity and further explore the association between paternal characteristics and very low birth weight.