The Time is Now: Equity and Inclusion in Newborn Quality Improvement

As maternal opioid exposure increased fourfold over a recent 15 year span,¹  the incidence of neonatal abstinence syndrome (NAS) grew from 1.6 cases per 1000 live births in 2004 to 8.8 in 2016.²  Given this growing number of affected infants, optimization and standardization of care for opioid exposed newborns (OENs) has great potential for impact. The Eat, Sleep, Console (ESC) assessment strategy is a relatively new approach focusing on the infant’s ability to feed, sleep, and be consoled in a timely manner.³  ESC is often used in conjunction with nonpharmacologic methods of management for infants with NAS. Evaluating the implementation and outcomes of the ESC strategy is an important and active area of research.^4,5 

Although infants with NAS are more likely to be White, NAS affects infants from all demographic groups; in 2016, 5.8% of infants diagnosed with NAS were Hispanic.²  Disparities in quality of care and outcomes have been found in Hispanic populations of newborns treated in the NICU^6,7 ; however, approaches to care that directly seek to address such gaps have been more limited. Therefore, evaluation of how outcomes resulting from interventions like ESC differ by race and ethnicity is a critically important area of inquiry. Before the study by Weikel et al⁸  in this issue of Hospital Pediatrics, little was known about differences in NAS management and outcomes in Hispanic and non-Hispanic populations. This study describes important factors about the care of patients with NAS and highlights equity factors warranting increased consideration in quality improvement (QI) projects more generally. This includes equity-oriented data collection and clear recognition of and approaches to mitigate ill effects of racism, ethnocentrism, and immigration status. Equity provides a lens through which to view opportunities for improved design and implementation of interventions, for example through codesign with families and/or underrepresented community members and equitable adaptation in implementation approaches for those who speak different languages.

In “Ethnic Disparities in the Care of Opioid-Exposed Newborns in Colorado Birthing Hospitals,” Weikel et al⁸  performed a secondary, stratified analysis of data collected quarterly during implementation of ESC across hospitals participating in the Colorado Hospitals Substance Exposed Newborn Quality Improvement Collaborative (CHoSEN QIC). In the initial CHoSEN QIC study, the primary outcomes were length of stay (LOS), percentage of OENs who received pharmacologic therapy, and LOS for OENs who received pharmacologic therapy. Implementation of ESC led to a reduction in overall LOS by 60% and a reduction in the percentage of OENs receiving pharmacologic therapy from 55.1% to 22.6%.⁹ 

In the subsequent secondary subanalysis of their 3-year study presented here, the authors focused on maternal–infant dyads with maternal ethnicity data included. This yielded a total enrollment of 799 dyads, of whom 241 identified as Hispanic.⁸  Here, Weikel et al⁸  evaluated the change in LOS and pharmacologic therapy use in Hispanic and non-Hispanic patients. Implementation had sought to decrease LOS and the percent of OENs receiving pharmacologic therapy. Both Hispanic and non-Hispanic groups experienced decreases in LOS and receipt of pharmacologic therapy. Yet, there was a delay of three-quarters (9 months) in reaching special cause for LOS reduction among Hispanic OENs. Hispanic OENs also experienced a one-quarter delay in reaching special cause for a decrease in the percentage receiving pharmacologic therapy. For secondary outcomes, no change in breastfeeding eligibility or the percent of eligible infants who received breast milk was noted across the entire sample or either subgroup.⁸ 

Although the authors should be commended for evaluating equity in outcomes resulting from ESC implementation in CHoSEN QIC hospitals, there are limitations in their data that could influence interpretation and serve as a guide for future interventions. For instance, Weikel et al⁸  discuss language barriers as potential contributors to the delay in reaching special cause. They also note that, in the initial planning of CHoSEN QIC, there was not explicit implementation guidance for Spanish-speaking families. Perhaps as a result, there is a striking amount of missing data on language among those included in the study, with >45% of Hispanic dyads with an unknown primary language.⁸  Thus, it is difficult to make determinations about the impact of primary language on the delays in change for the Hispanic group. Consideration of potential impacts of patient language in the design phase of QI studies is important in ensuring equitable implementation as well as evaluation of interventions. This is particularly true when notable gaps or delays arise, as they did in this study.

In addition to language, the authors name social factors such as systemic racism, discrimination, and segregation as potential contributors to the lag in improvement. It is important to also name potential factors within hospitals that may lead to differences in implementation like implicit biases and differences in hospital care at baseline. A previous study revealed differences in pharmacologic treatment rates between Black (70%) and White infants (84%) with NAS.¹⁰  It is interesting to note that in in the study by Weikel et al,⁸  during the baseline year, 47.1% of Hispanic OENs were treated with pharmacologic therapy compared with 59.1% of non-Hispanic OENs.⁸  This difference is similar to the observed difference in baseline treatment between Black and White infants and prompts key questions. Are we seeing undertreatment of Hispanic OENs or overtreatment of non-Hispanic OENs? Does undertreatment of pain and symptoms in minoritized people begin in infancy? If so, is it driven by similar factors driving known disparities in pain management for older children and adults?^11,12 

Obstacles associated with immigration status may also contribute to disparities. Researchers in a recent study found that immigration-related fears led to decreased public benefit use.¹³  Thus, immigration status could have implications for implementation of initiatives, like ESC, that involve ongoing interactions between parents and service providers and require trust to be built. Indeed, with parental involvement being a key component in the nonpharmacologic treatment methods, any decrease in parental presence and/or parental stress could lead to differences in outcomes. Additionally, Hispanic mothers were hypothesized to have a lack of adequate medical support, given their higher illicit opioid use compared with non-Hispanic mothers, and immigration status could be a driver. Gaining a more complete understanding of how to improve access to a range of care approaches could be an area of future work. Altogether, many potential factors, from systemic and structural inequities to in-hospital biases and care differences, could have driven delays in reaching special cause. These factors should be considered in QI implementation and evaluation of outcomes to address disparities.

Indeed, the ways in which QI initiatives are implemented can influence the degree to which those same initiatives narrow, or widen, disparities.^14,15  There is a very real possibility that QI may improve outcomes overall but widen gaps between certain populations. As such, we suggest that equity must be better integrated into QI initiatives from the earliest phases. We outline potential mechanisms for integration in Table 1. Before initiation, or implementation, of QI interventions, determination of study measures, including measures of disparities and comparator groups, should be carefully considered.¹⁶  This requires elucidation of accurate and complete data on characteristics like race, ethnicity, and language.¹⁷  Next, critical to all QI is the formation of the improvement team. In the CHoSEN QIC study, the multidisciplinary team was lacking caregiver representation and, more specifically, was missing Hispanic caregiver representation, or at a minimum Hispanic community representatives.⁹  Although the authors hypothesize some potential barriers standing in the way of improvements across subpopulations, hearing directly from those who have first-hand knowledge of the experience would be most helpful and enlightening. A caregiver may have been able to predict, and assist in overcoming, challenges posed by language or cultural barriers.

Furthermore, understanding the context into which an intervention is implemented is an important area that early caregiver representation may help address. For example, because Hispanic mothers experience unique challenges with breastfeeding, such as cultural assimilation and pressure to work often without breastfeeding supports,^18,19  cultural norms of feeding and newborn care may make ESC more challenging to implement without tailored approaches for certain individuals or groups. Consideration of cultural norms and contextualization of ESC may lead to improvements experienced by all and at an equitable pace. In addition to tailoring interventions for specific groups as a means of moving toward equitable outcomes, understanding that race, ethnicity, and language are proxies for inequitable practices that underlie disparities, such as racism and ethnocentrism, is an important tenet for equity-integrated QI. By highlighting potential areas for equity integration in CHoSEN QIC, we hope future QI initiatives will consider the outlined steps in their own QI efforts.

This analysis, and the eventual elimination, of an outcome gap between Hispanic and non-Hispanic OENs, highlights the overdue need for an equity-minded and equity-integrated approach to QI. As care teams implement new tools and therapies to improve the care of infants and children, equity should not be an afterthought, but instead a forethought. Unique populations should be included in development of QI initiatives so that the obstacles they face can be addressed early and often. Only then will all have the opportunity to experience outcomes in timely, equitable ways.