Disparities in Neonatal Intensive Care: Causes, Consequences and Charting the Path Forward

We are living through a fraught moment. The United States is grappling with the consequences of systemic racism and injustices perpetuated on its racial and ethnic minorities. At the same time, the disproportionate impact of the ongoing COVID-19 pandemic on minority communities has laid bare costs, in livelihoods and lives, extracted by structural inequities in our society.¹ Racism and inequality exert a profound impact on the health and well-being of racial/ethnic minorities, driving disparities across the life course, including for newborn infants and mothers.

This special issue of Seminars in Perinatology focuses on disparities in newborn health with a particular focus on the most vulnerable: preterm infants requiring care in the neonatal intensive care unit (NICU). The health of newborns has always served as measure of a healthy society. A deeply troubling reality in the United States is the existence of stark racial/ethnic disparities in the care and outcomes of neonates: Black neonates not only have a higher risk of preterm birth but they die at more than twice the rate of white neonates.² Black and Hispanic neonates are also at increased risk of severe neonatal morbidities.³ Understanding the causes of these disparities and implementing solutions remains an urgent public health imperative. This issue brings together scholarship that rises to this challenge with both rigor and a sense of urgency.

Health outcomes experienced by minorities are fundamentally rooted in their experience of social disadvantage characterized by adverse social and economic conditions. Racism and sexism exacerbate social disadvantage for minority women. Barfield reviews⁴ the role of social disadvantage on adverse outcomes of pregnancy including preterm birth, highlighting the role played by poverty, unemployment, low educational attainment and lack of health insurance. Barfield also identifies solutions to ameliorate social disadvantage and improve outcomes of care through specific interventions that address social and structural determinants of health.

Causes of preterm birth encompass social and biological factors. Social factors determine the psychosocial and physical environment that is ultimately reflected in the biologic response pathway that leads to premature birth, and its associated morbidities and mortality. Understanding the mechanisms by which specific environmental exposures act via sets of genetic variants to influence preterm birth is an important scientific goal. Stevenson and colleagues⁵ make the case for better integration of social and biological pathways in order to identify predictive, preventive and curative approaches to the problem of preterm birth.

Disparities in maternal and newborn health have shared causal pathways. And yet disparities research, as currently organized, considers these intertwined disparities as largely separate areas of inquiry. Glazer and co-authors⁶ suggest that the mother-infant dyad is the appropriate unit of analysis to study and ameliorate the burden of obstetric and neonatal disparities. The authors describe the many advantages of the approach in improving the quality of care and outcomes for mothers and preterm infants.

Neonatal disparities are rooted in a complex set of intersecting social, biological and environmental factors. However, care in the NICU remains a highly effective intervention, with the potential to ameliorate social disadvantage. Addressing disparities in access and receipt of high quality NICU care can substantially improve outcomes for minority preterm infants. Ravi and co-authors⁷ make the case for a granular assessment of deficits in processes of care delivery that lead to disparities in outcomes and for collaborative partnerships between providers and families to address gaps in both technical and relational aspects of care delivery.

Care for preterm infants and their mothers is highly specialized and complex. Delivery of infants in hospitals with the capability to optimize delivery and provide risk-appropriate care for infants is critical to improved outcomes. Lorch and co-authors⁸ examine the importance of delivery hospitals to neonatal outcomes and highlight the variation in access to risk appropriate care as an important source of disparities.

Quality improvement (QI) approaches have the potential to reduce neonatal disparities. Parker and Hwang review⁹ the challenges and opportunities in implementing QI for disparity reduction and identify key components of a QI framework that is specifically tailored to meeting the needs of minority infants and families.

To reduce disparities and improve long-term outcomes of preterm infants, we need to address both the medical and social needs of infants and their families. Edwards and Horbar¹⁰ review and highlight the need for follow through, a comprehensive approach directed towards both infants and families, that seeks to identify and implement potentially better practices to improve care beginning before birth and continuing into childhood.

Preterm birth disproportionately affects low-income and minority populations, leads to substantial short- and long-term morbidity and is associated with high risk of recurrence in subsequent pregnancies. Jani and colleagues¹¹ describe an innovative study that leverages mobile technology to address maternal and infant needs in the post-partum period and following through to discharge into the community. The authors describe the co-design approach used to develop PretermConnect, a mobile application designed to address the social, emotional and health educational needs of women at high risk for preterm birth and for follow-up care of their preterm infant.

Taken together, articles in this issue span the landscape of disparities in preterm birth: from examining the underlying causes and consequences, to setting out a path of action to eliminate pernicious disparities in the care and outcomes of preterm infants. The connective thread that holds all the articles together is a sense of urgency that, we as a society can and should act to address these disparities. Racial/ethnic disparities in perinatal health care delivery system reflect societal ills that are driving disparities in health and wellbeing of minorities. Unequal care can widen these disparities. At the same time, concerted action can mitigate social disadvantage and improve outcomes for minority infants and mothers. Regional and national quality improvement networks such as the California Perinatal Quality Care Collaborative (CPQCC) and the Vermont Oxford Network (VON) have a vital role to play in facilitating this work in partnership with state agencies. At the federal level, funding for research to evaluate models of care that better serve minority populations is needed to advance the work. We hope that the rigor and scholarship that is reflected in the articles in this issue will bring a renewed focus to improving the health of preterm infants and families. To put it simply: it is time to act.