Postpartum Readmissons: Racial Disparities Abound

LAS VEGAS -- Compared to white women, black women were more likely to be readmitted to the hospital postpartum and to suffer severe maternal morbidity, including pulmonary hypertension and other complications, a researcher said here.

With data from the 2012-2014 National Inpatient Sample, 3.1% of black women were readmitted postpartum compared to 1.7% of white women, which was highly significant, reported Aleha Aziz, MD, of Columbia University Irving Medical Center in New York City.

Moreover, black women were associated with an increased risk of severe maternal morbidity compared to white women (adjusted RR 1.16, 95% CI 1.10-1.22), and 8.4% of the black women had pulmonary edema and acute heart failure versus 3.7% of white women. The latter risks were 126% greater among black women after adjustment for demographics, hospital factors, and comorbidities (95% CI 117%-136%).

At a presentation at the annual meeting of the Society for Maternal-Fetal Medicine, a black clinician who only identified himself as being from Sarasota, Florida, offered praise for this research, as well as potential solutions for this problem during the questions portion of the presentation.

"I've been coming here [to the conference] a long time, and we now have more papers being presented on disparities," he said. "Once we identify these patients, they need to come back sooner ... and these patients need a patient navigator because they have too much going on in their life. It could be anyone -- could be a medical student or resident. We need another way to get these patients back in early."

Aziz offered some related, but sobering statistics at the presentation -- including that black women are 1 to 3 times more likely than white women to die from pregnancy-related complications and more likely to have a preventable death. In addition, the risk for postpartum readmission is increasing -- with a rise of 25% from 2004 to 2011, Aziz noted.

She further characterized racial and ethnic disparities and maternal morbidity and mortality rates in the U.S. as "an important public health problem" -- one that medical organizations have become involved in. Recent statements from the American College of Obstetricians and Gynecologists (ACOG) and SMFM about optimizing postpartum care and emphasizing the need for clinical care and research to reduce differences in outcomes.

"This is a critical public health issue that is gaining traction," Aziz said.

In this study, Aziz and colleagues examined data from women ages 15-54 with a postpartum readmission included in the National Inpatient Sample from 2012 to 2014. Postpartum readmissions were identified using CDC algorithm and ICD-9-CM codes, and race and ethnicity was self-identified.

Risk for overall severe maternal morbidity was a CDC definition that included 21 diagnoses, such as shock, stroke, heart failure, and transfusion. Risk for significant complications that were anticipated to be "significantly prevalent" included 11 severe maternal morbidity outcomes, including acute renal failure, embolism, sepsis, and eclampsia.

Overall, there were about 207,000 readmissions, including about 97,000 white women, 47,000 black women, 33,000 Hispanic women, and 30,000 defined as "other."

Black and Hispanic women were more likely to receive Medicaid, and black women had the highest comorbidity indices and highest rates of preeclampsia, Aziz said. In addition, higher portions of black women versus white women had significant complications, including renal failure, acute respiratory distress syndrome (ARDS), eclampsia, and stroke.

Aziz noted that while risk of hysterectomy, shock, sepsis, and transfusion were not significantly increased in black women, they were increased in white women.

However, when an audience member asked about this, Aziz said that when considering the likelihood of readmission, "those numbers change." For total delivery hospitalizations, black women are at similar risk of hysterectomy and at greater risk for transfusion, Aziz said.

Limitations to the analysis include that the data were cross-sectional and not linked to postpartum readmission.

Aziz concluded that identifying risk factors in black women that contribute to differentials in readmissions and severe maternal morbidity is necessary, and at least three severe maternal morbidity diagnoses related to hypertensive disorders were more prevalent in black women.