Postpartum emergency department care affected by sociodemographic characteristics

Postpartum emergency department (ED) visits are more common among Black and Hispanic patients, according to a recent study published in JAMA Network Open.

Maternal mortality rates doubled in the United States from 1991 to 2014, with most maternal deaths occurring postpartum. While risk factors for severe maternal mortality are known, poor postpartum outcomes still occur in the United States, with preventable ED visits being an indicator of increased morbidity risk.

Research has been ongoing on morbidity and mortality differences between racial and ethnic groups, with evidence indicating access to care and communication with a medical team are key factors to reduce postpartum visits in racial and ethnic minority groups. However, it is unknown if this is a widespread truth, nor how hospital factors affect avoidable postpartum ED visits.

To determine the association between patient and birth hospital characteristics with postpartum ED visits, investigators conducted a cross-sectional study of obstetric discharges from January 1, 2014, to November 16, 2016. The International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 were used to determine obstetric discharges.

As guidelines suggest an initial postpartum visit occurswithin 42 days of giving birth, postpartum ED visits during this period were included in the study. The postpartum ED visit rate was defined as the proportion of patients with at least 1 postpartum ED visit within 42 days of obstetric discharge. The primary ICD-9 or ICD-10 codes associated with the first study visit were analyzed.

Maternal characteristics included insurance, race, age, and home zip code income quartile, with ED visit rates stratified by race and hospital type. Race and ethnicity data were gathered from the Health Care Utilization Project databases.

Perinatal complications for vaginal, cesarean, and operative vaginal birth types were variables associated with severe maternal morbidity. Hospital characteristics included serving racial and ethnic groups disproportionately, safety net status, teaching status, metropolitan vs nonmetropolitan location, and obstetric volume.

Of the 608,559 eligible births, 8.7% were Asian, 14.9% Black, 16.7% Hispanic, and 45.3% White. Medicaid insurance was seen in 48.1%, while private insurance was seen in 47.7%. The average maternal age was 28.4 years.

An ED visit within 42 days of birth was seen in 5.8% of patients, while 0.9% had 2 or more ED visits in this time and 0.9% had readmission from the ED. Patients who were Black, Hispanic, younger than 30 years at delivery, covered by Medicaid insurance, and from the lowest or second lowest income quartiles were more likely to have postpartum ED visits. 

Minority-serving hospitals, safety net hospitals, and small- to medium-sized hospitals were more likely to see postpartum ED visits. When adjusting for hospital characteristics, patients aged under 20 years and those aged 25 to 29 years were at a greater risk of postpartum ED visits than patients aged 30 to 34 years.

Reference

Zarrin H, Vargas-Torres C, Janevic T, Stern T, Lin MP. Patient sociodemographics and comorbidities and birth hospital characteristics associated with postpartum emergency department care. JAMA Netw Open. 2023;6(3):e233927. doi:10.1001/jamanetworkopen.2023.3927