Disparities in Pregnancy-Associated Injury Morbidity Related to Race and Ethnicity, Age and Health Insurance

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Disparities in Pregnancy-Associated Injury
Morbidity Related to Race and Ethnicity, Age and
Health Insurance

• Angela Nannini, FNP, PhD
• Northeastern University SON and MA DPH
• 11th Annual MCH Epidemiology Conference
• Miami, Florida
• December 8, 2005

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Co-Authors

• Northeastern University, School of Nursing
• Jane Lazar, RN, MPH
• CDC , Division of Reproductive Health
• Cynthia Berg, MD, MPH
• Kay Tomashek, MD, MPH
• Massachusetts Department of Public Health
• Wanda Barfield, MD, MPH
• Boston University School of Public Health
• Mary Barger, CNM, MPH
• Milton Kotelchuck, MPH, PhD
• Howard Cabral, PhD
• Lawrence General Hospital
• Barbara Herbert, MD
• Thanks to Funding Entities

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Background

• Pregnancy-associated injuries (PAI) mortality in
  MA,
• 1/3 of all pregnancy-associated deaths 1990-2003
  
• Significant disparities in PAI mortality ratios
• Black non-Hispanic (BNH), or Hispanic, vs. white
• Younger (under age 25) vs. older
• Public vs. private payer
• Little is known about PAI morbidity
• Longitudinally linked data enables examination of
  entire pregnancy-associated period and
  woman-based analyses
• Emergency department data are potential rich
  information source about injuries

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Objectives

• Describe distribution of PAI
• Overall
• Intent
• Data source
• Timing in relation to the pregnancy
• Report rates of PAI morbidity for MA
• Assess disparities for PAI morbidity

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Longitudinal Maternal-Linked DataPregnancy to
Early Life Longitudinal (PELL) system
Birth/Fetal Death Certificate linked to
Hospitalization
Hospital Discharge and Observational Stay
Emergency Department
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Study Population

• All MA resident women with
• Pregnancy beginning after September 30, 2001 and
• An outcome of a live birth or fetal death gt 20
  weeks before October 1, 2003
• N 96,337 women with one pregnancy and full
  antenatal and postpartum follow-up

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Methods

• Create an analytic database from PELL to include
  all maternal utilization during PAI period
• Identify PAI
• ICD-9-CM codes 800-999.99 with exclusions noted
  by Weiss, 1999
• Examine distributions of PAI injuries visits by
• Data source
• Intentional and unintentional injuries (ICD-9 E
  codes)
• Antenatal and postpartum timing

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Methods

• Calculate rates of PAI morbidity overall and by
• race/Hispanic ethnicity
• health insurance status at delivery
• age group
• education
• Calculate relative risks with 95 confidence
  intervals (C.I.) for PAI morbidity for groups
  above
• Calculate relative risks for race/Hispanic
  ethnicity by payer, age and education strata

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Results
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Distribution of PAI

• 13.5 (n 13,026) women had 1 or more PAI
• 22.5 (n 2,933) injured women had gt 1 PAI visit
• 17,566 injury visits
• 16.1 of all non-delivery utilization
• Intent coded as
• 91 unintentional
• 7 intentional
• 1 self-inflicted
• 6 assault

N96,337 women
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Distribution of PAIby Data Source

• Emergency visits account for majority of PAI
  visits

166 PAI visits at delivery excluded
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Distribution of PAI by data source and antenatal
or postpartum Periods

• Linked file yields 39 more antenatal injury
  visits than methods identifying injury visits
  with pregnancy codes

166 PAI visits at delivery excluded
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Distribution of PAI visits by trimester in
pregnancy/postpartum
Postpartum
Antenatal
N17,400 visits
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Rates of PAI by race Hispanic ethnicity
23
18
18
12
13.5
7
N13,026
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Rates of PAI by age group
27
24
14
13.5
9
9
N13,026
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Rates of PAI by payer at delivery or education
level
24
23
18
13.5
11
10
N13,026
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Relative risks for PAI by Race/Ethnicity or
Education
Unadjusted Relative Risk 95 CI
Race/Ethnicity
Black NH 1.90 1.8, 2.0
Hispanic 1.51 1.4, 1.57
Asian NH 0.50 0.49,0.60
White NH 1.00
Education
ltHS 2.50 2.4, 2.6
HS 1.80 1.77, 1.9
gtHS 1.00
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Relative risks for PAI by Age or Insurer at
Delivery
Unadjusted Relative Risk 95 CI
Age
lt 20 1.90 1.8, 2.0
20-24 1.70 1.6, 1.7
25-29 1.00
30-34 0.65 0.6, 0.7
gt 35 0.61 0.57, 0.67
Payer
Public 2.17 2.10, 2.24
Private 1.00
Other 0.91 0.76, 1.07
N13,026
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Relative risks for PAI by race/Hispanic ethnicity
payer strata
Public RR (95 CI) Private RR (95 CI)
Race/Ethnicity
Black NH 1.04 (0.97, 1.11) 2.20 (2.08,2.37)
Hispanic 0.74 (0.70, 0.76) 1.86 (1.74,1.98)
Asian NH 0.83 (0.97, 0.68) 0.54 (0.48, 0.61)
White NH 1.00 1.00
NS
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Relative risks for PAI by race/Hispanic ethnicity
education strata Reference White NH
RR (95 CI) RR (95 CI) RR (95 CI)
Race/Hispanic ltHS HS gtHS
Black NH 1.02 (0.92,1.13) 1.34 (1,20, 1.51) 2.21 (2.05,2.36)
Hispanic 0.68 ( 0.64,0.74) 1.06 (0.99, 1.14) 1.68 (1.54,1.82)
Asian NH 0.43 (0.37,0.52) 0.51 (0.42,0.61 ) 0.52 (0.45,0.59)
NS
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Relative risks for PAI by race/Hispanic ethnicity
age strata Reference White NH
Race/Hispanic RR (95 CI) lt24 RR (95 CI) 25-29 RR (95 CI) gt 30
Black NH 1.15 (1.06,1.23) 1.62 (1.47,1.78) 2.28 (2.11,2.47)
Hispanic 0.87 (0.82,0.92) 1.22 ( 1.11,1.33) 1.53 (1.39, 1.68)
Asian NH .52 (.44,.61) 0.38 (0.31,0.46) 0.66 (0.57,0.76)
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Conclusions

• Overall 1 in 7 women experience PAI but as high
  as 1 in 4 for some groups
• Majority PAI coded as unintentional
• Rates PAI in 3rd antenatal trimester and 1st
  trimester postpartum
• Unadjusted RR mirror disparities found for PAI
  mortality
• Stratified results yield a more complex picture
• Population based linked file with emergency
  visits enables women-based analyses and aids
  understanding of PAI

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Limitations

• Does not include pregnant women w/o fetal death gt
  20 weeks or live birth
• Severity of injuries were not assessed
• May underestimate rate
• 5 of women did not have identifier for
  longitudinal link
• More analyses needed to understand
• Interactions
• specific causes of PAI
• differences between other women of reproductive
  age to plan public health interventions

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Questions or comments please contact me at
a.nannini_at_neu.edu
Thank You!!