Racial disparities in care escalation for postpartum hemorrhage requiring transfusion

Abstract

Background: Postpartum hemorrhage is a leading cause of maternal morbidity and mortality in the United States and disproportionately affects pregnant persons of color.

Objective: This study aimed to identify the demographic and obstetrical characteristics of those who received different levels of antihemorrhagic intervention in the setting of severe postpartum hemorrhage requiring blood transfusion.

Study design: This was a retrospective cohort study of patients with documented postpartum hemorrhage (estimated blood loss of ≥1000 mL) and blood product transfusion. Moreover, 3 levels of antihemorrhagic intervention were defined as follows: level 1, administration of uterotonics only; level 2, performance of a procedure (ie, B-Lynch suture, O'Leary stitch, Bakri balloon, dilation and curettage, laceration repair, or embolization); and level 3, hysterectomy. Maternal demographics, obstetrical characteristics, and comorbidities were extracted from electronic health records. Ordinal logistic regression was used to estimate the odds of higher intervention levels adjusting for maternal demographic and obstetrical characteristics.

Results: Of note, 365 patients were included in this study, with a racial or ethnic composition of 30% White, 42% Black, 18% Hispanic, and 10% other. Moreover, 233 patients (64%) received level 1 intervention, 98 patients (27%) received level 2 intervention, and 34 patients (9%) received level 3 intervention. Patients receiving higher levels of intervention were more likely to have greater estimated blood loss (P<.001), have more transfusions (P<.001), and be of advanced maternal age (P=.004). Black and Hispanic patients were less likely to have received higher levels of intervention than White patients (P=.034). After adjusting for estimated blood loss, advanced maternal age, placenta accreta spectrum, and fibroids, Black patients remained significantly less likely to receive higher levels of intervention (adjusted odds ratio, 0.55; 95% confidence interval, 0.30-0.98). This difference persisted at an estimated blood loss of ≥3000 mL, with Black and Hispanic patients being significantly less likely to receive higher levels of intervention than White patients (odds ratio, 0.31 [95% confidence interval, 0.10-0.92] and 0.10 [95% confidence interval, 0.01-0.53], respectively).

Conclusion: Among patients experiencing postpartum hemorrhage and receiving transfusion, Black patients are less likely to receive higher levels of antihemorrhagic intervention. This disparity is concerning in this high-risk population and requires further attention and investigation.

Keywords: antihemorrhagic intervention; blood loss; hysterectomy; maternal morbidity; obstetrics; postpartum hemorrhage; pregnancy; racial disparities; retrospective cohort study; transfusion.

FIGURE 1. Postpartum hemorrhage management algorithm

The management of postpartum hemorrhage requires first identifying the source of bleeding, followed by targeted medical management, procedural intervention, and transfusion. For severe intractable bleeding, a hysterectomy is definitive management. D&C, dilation and curettage; FFP, fresh frozen plasma; pRBC, packed red blood cells.

FIGURE 2

Flowchart for inclusion and exclusion criteria of study population, 2015–2020 AHI, antihemorrhagic intervention; PPH, postpartum hemorrhage; pRBC, packed red blood cells.

FIGURE 3

Definitions of 3 levels of antihemorrhagic intervention

FIGURE 4. Adjusted odds ratio for higher level of intervention by race and ethnicity

Data have been adjusted for maternal race and ethnicity, advanced maternal age, placenta accreta spectrum, fibroids, and estimated blood loss. Asterisk denotes P value of <.05 is considered significant. aOR, adjusted odds ratio; CI, confidence interval.

FIGURE 5. Intervention stratified by race and ethnicity and EBL

Asterisk denotes P value of <.05 is considered significant. CI, confidence interval; EBL, estimated blood loss; OR, odds ratio.