The analysis then adjusts scores to account for the length of the mother’s pregnancy, whether the mother received prenatal care, whether the baby was from a single or multiple birth, the baby’s 5-minute Apgar score (a quick assessment of the infant’s physical health at birth) and whether delivery was by cesarean section.

Scores were also statistically adjusted to reflect the fact that some hospitals cared for sicker babies, on average, than others. The final score for each hospital, and for each group of patients within a hospital, reflects whether the hospital did the same, better or worse than would be expected in addressing their patients’ medical problems. Scores were calculated separately for white, black, Hispanic, Asian and “other” infants and referenced for each subgroup against whites.

When researchers analyzed the population of very low birth weight infants in their study, Hispanic infants and those with “other” ethnicity had lower Baby-MONITOR scores than white infants, while black and Asian infants did not have significantly different scores than whites. However, across the state, white infants scored higher on measures of whether standard medical practices were being followed. For instance, 89 percent of white infants and 88 percent or Asian infants in the study received steroids before birth to mature their lungs, while 87 percent of Hispanic infants and 85 percent of black infants got the same treatment. The difference remained statistically significant after adjusting for possible confounding factors.

Black infants had lower rates than white infants of receiving any human milk at discharge — an indicator of worse outcomes — but also had better outcomes in some areas, including faster growth rates and lower rates of chronic lung disease and collapsed lung. Hispanic infants did worse than whites on all components of the score except collapsed-lung rates.

Across NICUs, those that provided the poorest quality of care tended to have the smallest disparities between ethnicities; in some, blacks fared better than white infants. As quality scores rose across hospitals, white infants tended to do better.

The researchers also found that although racial and ethnic differences in NICU care were fairly small when examined across California as a whole, some individual hospitals had large gaps in how they cared for infants from different racial and ethnic backgrounds.

Individualizing care

Addressing the disparities will require a nuanced approach, Profit said. “It’s really important for NICUs to individualize care to the patient population they see,” he said.

For instance, Hispanic families who are primarily Spanish-speaking may be experiencing language barriers that make it harder for parents to ask questions and act as advocates for their infants. “For them, having access to translation and personnel who speak Spanish is really critical,” he said. Hospitals serving a larger proportion of African-American infants may have different issues they need to address.

For many of these infants, their time in the NICU sets them on track for their entire life.

The next step, Profit said, is to help California’s NICUs identify ways in which they can each make progress in treating all infants more equitably. “Our goal is to develop a dashboard of disparity measures for NICUs throughout California so that each can see how they’re performing for infants of different races and ethnicities in comparison to their peers,” he said. The feedback will become part of the work of the California Perinatal Quality Care Collaborative, which has organized successful quality-improvement initiatives to help NICUs across the state improve the medical care they deliver. The researchers are also working with the Vermont Oxford Network, a sister organization that monitors NICUs across the country to provide similar feedback to hospitals nationwide.

“We need to continue to identify vulnerable populations, make sure they get their needs met and find better ways to engage all families in our care,” Profit said.

Hospital care during the newborn period is not the largest contributor to health disparities that minority infants experience, Profit noted, estimating that socioeconomic and biological differences likely make a larger contribution. Nevertheless, that does not mean disparities in medical care should be ignored, he added.

“For many of these infants, their time in the NICU sets them on track for their entire life,” Profit said. “If we can get things right early on, that could have a huge long-term effect.”

Other Stanford collaborators on the research are Jeffrey Gould, MD, professor of pediatrics; biostatistician Mihoko Bennett, PhD; Ciaran Phibbs, PhD, associate professor of pediatrics; and Henry Lee, MD, associate professor of pediatrics. Profit, Gould and Lee are members of Stanford’s Child Health Research Institute.

Researchers at Duke University School of Medicine and the University of California-Santa Cruz also contributed to the work.

The study was supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (grants R01HD083368, R01HD08467 and K23HD068400).

Stanford’s Department of Pediatrics also supported the work.