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. 2024 May 1;178(5):454-464.
doi: 10.1001/jamapediatrics.2024.0125.

Social Determinants of Health and Redirection of Care for Infants Born Extremely Preterm

Jane E Brumbaugh  1 , Carla M Bann  2 , Edward F Bell  3 , Colm P Travers  4 , Betty R Vohr  5 , Elisabeth C McGowan  5 , Heidi M Harmon  3 , Waldemar A Carlo  4 , Susan R Hintz  6 , Andrea F Duncan  7 ; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network
Collaborators, Affiliations

Social Determinants of Health and Redirection of Care for Infants Born Extremely Preterm

Jane E Brumbaugh et al. JAMA Pediatr. .

Abstract

Importance: Redirection of care refers to withdrawal, withholding, or limiting escalation of treatment. Whether maternal social determinants of health are associated with redirection of care discussions merits understanding.

Objective: To examine associations between maternal social determinants of health and redirection of care discussions for infants born extremely preterm.

Design, setting, and participants: This is a retrospective analysis of a prospective cohort of infants born at less than 29 weeks' gestation between April 2011 and December 2020 at 19 National Institute of Child Health and Human Development Neonatal Research Network centers in the US. Follow-up occurred between January 2013 and October 2023. Included infants received active treatment at birth and had mothers who identified as Black or White. Race was limited to Black and White based on service disparities between these groups and limited sample size for other races. Maternal social determinant of health exposures were education level (high school nongraduate or graduate), insurance type (public/none or private), race (Black or White), and ethnicity (Hispanic or non-Hispanic).

Main outcomes and measures: The primary outcome was documented discussion about redirection of infant care. Secondary outcomes included subsequent redirection of care occurrence and, for those born at less than 27 weeks' gestation, death and neurodevelopmental impairment at 22 to 26 months' corrected age.

Results: Of the 15 629 infants (mean [SD] gestational age, 26 [2] weeks; 7961 [51%] male) from 13 643 mothers, 2324 (15%) had documented redirection of care discussions. In unadjusted comparisons, there was no significant difference in the percentage of infants with redirection of care discussions by race (Black, 1004/6793 [15%]; White, 1320/8836 [15%]) or ethnicity (Hispanic, 291/2105 [14%]; non-Hispanic, 2020/13 408 [15%]). However, after controlling for maternal and neonatal factors, infants whose mothers identified as Black or as Hispanic were less likely to have documented redirection of care discussions than infants whose mothers identified as White (Black vs White adjusted odds ratio [aOR], 0.84; 95% CI, 0.75-0.96) or as non-Hispanic (Hispanic vs non-Hispanic aOR, 0.72; 95% CI, 0.60-0.87). Redirection of care discussion occurrence did not differ by maternal education level or insurance type.

Conclusions and relevance: For infants born extremely preterm, redirection of care discussions occurred less often for Black and Hispanic infants than for White and non-Hispanic infants. It is important to explore the possible reasons underlying these differences.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Bann reported grants from the National Institute of Child Health and Human Development during the conduct of the study. Dr Travers reported grants from the National Heart, Lung, and Blood Institute during the conduct of the study and grants from the American Heart Association and Owlet Baby Care outside the submitted work; in addition, Dr Travers reported a patent pending for a bradycardia predictor and interrupter. Dr Hintz reported grants from the National Institute of Child Health and Human Development Neonatal Research Network during the conduct of the study. No other disclosures were reported.

Figures

Figure.
Figure.. Flow Diagram
aParticipants may meet more than 1 of the exclusion criteria. bParticipants may have more than 1 social determinant of health (SDOH) associated with under-resourced status.
See this image and copyright information in PMC

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