Obstetric Unit Closures and Racial/Ethnic Differences in Severe Maternal Morbidity in the State of New Jersey

ABSTRACT Background In the United States, racial disparities in maternal morbidity and mortality are pronounced and persistent. While the maternal mortality ratio (MMR) and severe maternal morbidity (SMM) rates have increased over the past 30 years, the number of obstetric (OB) units in the country has simultaneously diminished. Black women are 3 times more likely to die in childbirth than White women, and twice as likely to suffer SMM (or a near miss). Between 2003 and 2013, 366 (10%) of OB units closed, and rural OB unit closures were more likely in Black communities. The state of New Jersey (NJ) has the highest Black MMR (131.8/100,000 live births) of all states reporting this data. Very few studies have examined the role urban OB unit closures play in racial/ethnic disparities in maternal health outcomes. Objective To analyze racial differences in SMM in New Jersey hospitals among women experiencing the loss of their nearest OB unit during the years 2006-2015. Study Design This study used data on all births in NJ hospitals (2006 – 2015) by women living in ZIP code tabulation areas (ZCTAs) that lost their nearest OB unit over that period. Severe maternal morbidity was measured using a composite variable for severe illness during hospitalizations (e.g. acute heart failure, acute renal disease, disseminated intravascular coagulation, sepsis) identified using the International Classification of Diseases, Ninth Revision. Logistic regression models were used to analyze the associations between race/ethnicity on individual likelihood of SMM, adjusting for annual trends, individual socioeconomic characteristics, age, pre-existing conditions, and delivery hospital characteristics (i.e. percent Black patients >25% [Black-serving hospital] and percent Medicaid discharges in the delivery OB). Results There were 227,412 delivery hospitalizations among women who lived in the 124 NJ ZCTAs that lost the nearest OB unit from 2006-2015. Black women had the highest SMM rates, increasing from 1.2% in 2006 to 2.3% in 2015. The Black-White gap remained similar in magnitudes over the period, as White women's SMM rates increased from 0.7% to 1.4%. However, for Hispanic women, SMM increased dramatically from 0.7% in 2006 to 2.4% in 2013, followed by a decreasing trend during 2013-2015. When adjusting for individual factors, the odds of SMM among all women was greater if they delivered after the loss of the nearest OB unit (Adjusted Odds Ratio (AOR)=1.55, 95% Confidence Interval (CI = (1.30, 1.86)). Hispanic women experienced the greatest increase in SMM, regardless of whether they delivered before or after their nearest OB unit closed. For all women, delivering in a Black-serving OB was associated with a greater likelihood of individual SMM (AOR = 1.36, 95% CI= (1.19, 1.56). Conclusion Racial/ethnic disparities in SMM persist and might be exacerbated by nearby obstetric unit closures. In New Jersey ZIP codes with OB unit loss, the Hispanic-White gap in SMM widened substantially, and SMM rates were also higher among women who delivered in Black-serving hospitals. Policymakers should take steps to prevent OB unit closures and to ensure that the resources available at Black-serving OBs are at least on par with those of other institutions.