Outcomes for preterm infants treated in NICUs have improved in the last 25 years but progress has been unequal.1 Persistent racial and ethnic disparities exist in this vulnerable population.2 Although disparities are rooted in a complex set of causes, there is increasing recognition that differential quality of care is a contributing factor.3,5 Minority infants are more likely to receive care at poor-quality NICUs5,6 and more likely to receive worse care than white infants within a NICU.3 African American and Hispanic infants are at particular risk. Eliminating deficits in the quality of care for minority infants requires a granular understanding of differences in care across different racial and ethnic groups.

In this issue of Pediatrics, Boghossian et al7 evaluate racial and ethnic differences over time in care practices for 215 000 infants born at 22 through 29 weeks’ gestation between January 2006 and December 2017 at US centers of the Vermont Oxford Network, a voluntary network of NICUs focused on quality improvement (QI). This study has several strengths: a national data set drawn from 789 NICUs representing 88% of all US births at 22 to 29 weeks’ gestation and attention to a continuum of care practices from obstetric care to delivery room and NICU care. Results over the 12-year time frame examined offer a mixed picture. The good news is that disparities have narrowed over time for some care practices and outcomes. Compared with white infants, African American infants experienced faster improvements in mortality, hypothermia on admission, necrotizing enterocolitis, and late-onset sepsis. Hispanic infants experienced faster improvements in mortality, respiratory distress syndrome, and pneumothorax. However, mortality and several morbidities remained elevated, especially for African American infants.

Where does this study fit in the landscape of neonatal disparities research? There is an urgent need to shift efforts from documenting disparities to identifying and implementing effective solutions. Boghossian et al7 offer several pointers for disparity solutions. First, even as we are increasingly conscious of the origin of disparities in adverse social conditions,8 high-quality clinical care remains critical for improving outcomes among minority preterm infants. We have made some progress in reducing the quality deficit, but hidden in the averaged improvements may be substantial regional5 and unit-level variation3 where minority infants risk receiving worse care. NICUs that predominantly serve minority populations are important targets for improvement efforts. Second, the authors of this study set the stage for asking more focused questions: Why have disparities narrowed for some outcomes and not for others? For specific individual outcomes, what processes of care contribute to disparity creation and how? What is the role of the care delivery structure and the way families are engaged in the NICU in creating disparities? Third, the study suggests a need for research that illuminates the drivers of disparities and quality measures to monitor such drivers for improvement activities. To illustrate, Parker et al9 recently evaluated hospital practices in the use of mother’s milk in a large cohort of preterm infants in Massachusetts across different racial and ethnic groups. The authors found that initiation rates of mother’s milk did not vary by race, but substantial disparities emerged after 1 month of the birth hospitalization. Understanding the timing of disparity and its drivers will provide granular information for future improvement efforts.

The mechanisms of disparity creation are twofold: differential underlying risk status and differential access to effective interventions.10 The underlying risk status of preterm infants may be the result of factors outside the purview of the NICU. However, unequal access to high-quality NICU care is amenable to change. As we see from Boghossian et al7 and the broader literature,11 QI has the potential to ameliorate this disadvantage.12,13 When devising solutions, we need to consider why NICUs that predominantly serve minority populations appear to provide worse care5 and why, by some measures, minority infants appear to receive worse care within a NICU.14 Additionally, we need targeted efforts implemented in partnership with disadvantaged families to address specific drivers of disparity within and across units. QI efforts also need to be supported by disparity-sensitive measures of quality, including measures related to family engagement. In a previous study, we showed that many disparities are created through deficits in family-centered care, with infants becoming second victims of such shortcomings.15 Although family-centered neonatal care is readily accepted and innovative models are being evaluated with success,16 implementation varies.17 Existing assessment tools and inventories18,19 are based on surveys, making them impractical for monitoring and improvement at a population level. Ongoing measurement and feedback are critical for NICUs to engage minority families and improve family-centered care.20 

Disparities in care and outcomes for infants exist in many aspects of perinatal care. Boghossian et al7 show us that improvements have occurred in many aspects but work remains in many others. Efforts to address disparities also need to account for structural and interpersonal racism in the health care delivery system. QI provides a powerful tool to address disparities.

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

FUNDING: Supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01 HD083368-04 and RO1 HD084667-04) and the Stanford Maternal and Child Health Research Institute. Funded by the National Institutes of Health (NIH).

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-1106.

     
  • QI

    quality improvement

1
Horbar
JD
,
Edwards
EM
,
Greenberg
LT
, et al
.
Variation in performance of neonatal intensive care units in the United States.
JAMA Pediatr
.
2017
;
171
(
3
):
e164396
[PubMed]
2
Wallace
ME
,
Mendola
P
,
Kim
SS
, et al
.
Racial/ethnic differences in preterm perinatal outcomes.
Am J Obstet Gynecol
.
2017
;
216
(
3
):
306.e1
306.e12
3
Profit
J
,
Gould
JB
,
Bennett
M
, et al
.
Racial/ethnic disparity in NICU quality of care delivery.
Pediatrics
.
2017
;
140
(
3
):
e20170918
[PubMed]
4
Howell
EA
,
Janevic
T
,
Hebert
PL
,
Egorova
NN
,
Balbierz
A
,
Zeitlin
J
.
Differences in morbidity and mortality rates in black, white, and Hispanic very preterm infants among New York City hospitals.
JAMA Pediatr
.
2018
;
172
(
3
):
269
277
[PubMed]
5
Horbar
JD
,
Edwards
EM
,
Greenberg
LT
, et al
.
Racial segregation and inequality in the neonatal intensive care unit for very low-birth-weight and very preterm infants.
JAMA Pediatr
.
2019
;
173
(
5
):
455
461
[PubMed]
6
Howell
EA
,
Hebert
P
,
Chatterjee
S
,
Kleinman
LC
,
Chassin
MR
.
Black/white differences in very low birth weight neonatal mortality rates among New York City hospitals.
Pediatrics
.
2008
;
121
(
3
). Available at: www.pediatrics.org/cgi/content/full/121/3/e407
[PubMed]
7
Boghossian
NS
,
Geraci
M
,
Lorch
SA
,
Phibbs
CS
,
Edwards
EM
,
Horbar
JD
.
Racial and ethnic differences over time in outcomes of infants born less than 30 weeks’ gestation.
Pediatrics
.
2019
;
144
(
3
):
e20191106
8
Lorch
SA
,
Enlow
E
.
The role of social determinants in explaining racial/ethnic disparities in perinatal outcomes.
Pediatr Res
.
2016
;
79
(
1–2
):
141
147
[PubMed]
9
Parker
MG
,
Gupta
M
,
Melvin
P
, et al
.
Racial and ethnic disparities in the use of mother's milk feeding for very low birth weight infants in Massachusetts.
J Pediatr
.
2019
;
204
:
134
141.e1
10
Wise
PH
.
The anatomy of a disparity in infant mortality.
Annu Rev Public Health
.
2003
;
24
:
341
362
[PubMed]
11
Sigurdson
K
,
Mitchell
B
,
Liu
J
, et al
.
Racial and ethnic disparities in neonatal intensive care: a systematic review.
Pediatrics
.
2019
;
144
(
1
):
e20183114
12
Lee
HC
,
Kurtin
PS
,
Wight
NE
, et al
.
A quality improvement project to increase breast milk use in very low birth weight infants.
Pediatrics
.
2012
;
130
(
6
). Available at: www.pediatrics.org/cgi/content/full/130/6/e1679
[PubMed]
13
Beal
AC
.
High-quality health care: the essential route to eliminating disparities and achieving health equity.
Health Aff (Millwood)
.
2011
;
30
(
10
):
1868
1871
[PubMed]
14
Howell
EA
,
Holzman
I
,
Kleinman
LC
,
Wang
J
,
Chassin
MR
.
Surfactant use for premature infants with respiratory distress syndrome in three New York city hospitals: discordance of practice from a community clinician consensus standard.
J Perinatol
.
2010
;
30
(
9
):
590
595
[PubMed]
15
Sigurdson
K
,
Morton
C
,
Mitchell
B
,
Profit
J
.
Disparities in NICU quality of care: a qualitative study of family and clinician accounts [published correction appears in J Perinatol 2018;38(8):1123].
J Perinatol
.
2018
;
38
(
5
):
600
607
[PubMed]
16
O’Brien
K
,
Robson
K
,
Bracht
M
, et al;
FICare Study Group and FICare Parent Advisory Board
.
Effectiveness of Family Integrated Care in neonatal intensive care units on infant and parent outcomes: a multicentre, multinational, cluster-randomised controlled trial.
Lancet Child Adolesc Health
.
2018
;
2
(
4
):
245
254
[PubMed]
17
Petersen
MF
,
Cohen
J
,
Parsons
V
.
Family-centered care: do we practice what we preach?
J Obstet Gynecol Neonatal Nurs
.
2004
;
33
(
4
):
421
427
18
Davidson
JE
,
Aslakson
RA
,
Long
AC
, et al
.
Guidelines for family-centered care in the neonatal, pediatric, and adult ICU.
Crit Care Med
.
2017
;
45
(
1
):
103
128
[PubMed]
19
Eckle
N
,
MacLean
SL
.
Assessment of family-centered care policies and practices for pediatric patients in nine US emergency departments.
J Emerg Nurs
.
2001
;
27
(
3
):
238
245
20
Dhurjati
R
,
Sigurdson
K
,
Profit
J
.
Patient- and family-centered care as a dimension of quality.
Am J Med Qual
.
2019
;
34
(
3
):
307
308
[PubMed]

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.