Birth-Based vs Fetuses-at-Risk Approaches for Assessing Neonatal Mortality Rate by Race

Wu, Bohao; Taylor, Sarah N.; Shabanova, Veronika; Hawley, Nicola L.

doi:10.1001/jamapediatrics.2023.0333

Cited by 6 publications

(4 citation statements)

References 7 publications

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“…Although the fetus at risk approach and its modification is not universally accepted, 28 it focuses attention on the notion that burden to the clinician, as well as the family, is dependent upon both rate and volume. 29 Similar findings were reported by Wu et al who state that this paradox (the Black disadvantage estimated by the fetus at risk approach) seen when GA specific neonatal mortality rate is stratified by risk factors such as race, “may be explained if more neonates without congenital anomalies are born at earlier GA among Black vs White mothers.” 30 Our study of very preterm infants is limited to California, which may have population and healthcare-specific differences from other states. For example, our 2020 infant mortality of 3.92 is one of the lowest in the country.…”

Section: Discussionmentioning

confidence: 99%

Cohort selection and the estimation of racial disparity in mortality of extremely preterm neonates

et al. 2023

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Background Racial disparities in preterm neonatal mortality are long-standing. We aimed to assess how cohort selection influences mortality rates and racial disparity estimates. Methods With 2014–2018 California data, we compared neonatal mortality rates among Black and non-Hispanic White very low birth weight (VLBW, <1500 g) or very preterm infants (22–29 weeks gestational age). Relative risks were estimated by different cohort selection criteria. Blinder-Oaxaca decomposition quantified factors contributing to mortality differential. Results Depending upon standard selection criteria, mortality ranged from 6.2% (VLBW infants excluding first 12-h deaths) to 16.0% (22–29 weeks’ gestation including all deaths). Black observed neonatal mortality was higher than White infants only for delivery room deaths in VLBW infants (5.6 vs 4.2%). With risk adjustment accounting for higher rate of low gestational age, low Apgar score and other factors, White infant mortality increased from 15.9 to 16.6%, while Black infant mortality decreased from 16.7 to 13.7% in the 22–29 weeks cohort. Across varying cohort selection, risk adjusted survival advantage among Black infants ranged from 0.70 (CL 0.61–0.80) to 0.84 (CL 0.76–0.93). Conclusions Standard cohort selection can give markedly different mortality estimates. It is necessary to reduce prematurity rates and perinatal morbidity to improve outcomes for Black infants. Impact In this population-based observational cohort study that encompassed very low birth weight infant hospitalizations in California, varying standard methods of cohort selection resulted in neonatal mortality ranges from 6.2 to 16.0%. Across all cohorts, the only significant observed Black-White disparity was for delivery room deaths in Very Low Birth Weight births (5.6 vs 4.2%). Across all cohorts, we found a 16–30% survival advantage for Black infants. Cohort selection can result in an almost three-fold difference in estimated mortality but did not have a meaningful impact on observed or adjusted differences in neonatal mortality outcomes by race and ethnicity.

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Section: Discussionmentioning

confidence: 99%

Cohort selection and the estimation of racial disparity in mortality of extremely preterm neonates

et al. 2023

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“…Preterm birth (PTB; live-birth <37 weeks gestation) is the leading cause of death in children under age 5 years [1]. Among US singletons born without congenital anomalies, PTB prevalence increased from 7.6% to 8.1% [2] between 2014 and 2018, with Black women having the highest (11.2%) and White women having the lowest prevalence (7.2%) [2]. Pacific Islander women in the United States (PTB prevalence: 11.2%) [3] also have a higher risk of PTB compared with White women [3], but our understanding of risk factors underlying this disparity is limited because Pacific Islander individuals have been traditionally aggregated with Asian American individuals, whose demographic characteristics and biomedical risk profiles are quite dissimilar [4].…”

Section: Introductionmentioning

confidence: 99%

Pre‐pregnancy BMI, rate of gestational weight gain, and preterm birth among US Pacific Islander individuals

Wu,

Shabanova,

Taylor

et al. 2024

Obesity

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ObjectiveThe objective of this study was to examine the association between rate of gestational weight gain (GWG) and preterm birth (PTB) classified by pre‐pregnancy BMI among Pacific Islander individuals in the United States.MethodsPacific Islander mothers (n = 55,975) and singleton infants (22–41 gestational weeks) without congenital anomalies were included using data from the National Center for Health Statistics (2014–2018). PTB was compared by pre‐pregnancy BMI among women in each stratum of rate of GWG using Cox proportional hazards models.ResultsCompared with mothers with a rate of GWG within the guidelines, mothers with a rate of GWG below the guidelines and either pre‐pregnancy underweight (adjusted hazard ratio [aHR] = 1.84, 95% CI: 1.10–3.06), healthy weight (aHR = 1.38, 95% CI: 1.15–1.65), obesity class I (aHR = 1.22, 95% CI: 0.97–1.52), or obesity class II (aHR = 1.43, 95% CI: 1.05–1.96) had an increased risk of PTB; mothers with a rate of GWG above the guidelines and either pre‐pregnancy underweight (aHR = 1.57, 95% CI: 0.92–2.69) or obesity class II (aHR = 1.31, 95% CI: 0.98–1.76) had an increased risk of PTB.ConclusionsThe association between rate of GWG below or above the guidelines and PTB differs by pre‐pregnancy BMI among Pacific Islander individuals.

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“…There are several ways to address the induced selection bias. By applying the fetuses-at-risk approach, we recently demonstrated that neonatal mortality rate (<28 days) was roughly 3 times higher among Black neonates than White neonates born extremely preterm, which contrasted standard stratified (ie, biased) analysis where the neonatal mortality rate was slightly lower among Black neonates compared with White neonates born extremely preterm . In the setting of infant mortality, inverse-probability weighting may be an applicable approach to address collider stratification bias.…”

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confidence: 99%

Potential Selection Bias in Preterm Infant Mortality Study

Rogne,

Wu,

Hawley

2024

JAMA Pediatr

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Birth-Based vs Fetuses-at-Risk Approaches for Assessing Neonatal Mortality Rate by Race

Abstract: This cohort study assesses 5-year race-stratified neonatal mortality and prevalence of preterm births in the US using birth-based and fetuses-at-risk approaches.

Cited by 6 publications

References 7 publications

Cohort selection and the estimation of racial disparity in mortality of extremely preterm neonates

Cohort selection and the estimation of racial disparity in mortality of extremely preterm neonates

Pre‐pregnancy BMI, rate of gestational weight gain, and preterm birth among US Pacific Islander individuals

Potential Selection Bias in Preterm Infant Mortality Study

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