Social Determinants of Health and Redirection of Care for Infants Born Extremely Preterm
Authors: Brumbaugh Jane E. , Bann Carla M. , Bell Edward F. , Travers Colm P. , Vohr Betty R. , McGowan Elisabeth C. , Harmon Heidi M. , Carlo Waldemar A. , Hintz Susan R. , Duncan Andrea F. ,   Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network, Polin Richard A. , Laptook Abbot R. , Keszler Martin , Mayne Julie , Lamberson Vita , Keszler Mary L. , Hensman Angelita M. , Vieira Elisa , St. Pierre Lucille , Burke Robert T. , Alksninis Barbara , Leach Teresa M. , Watson Victoria E. , Knoll Andrea , Moffat Stephanie , Hibbs Anna Maria , Newman Nancy S. , Wilson-Costello Deanne E. , Siner Bonnie S. , Friedman Harriet G. , Truog William E. , Pallotto Eugenia K. , Kilbride Howard W. , Gauldin Cheri , Holmes Anne , Johnson Kathy , Scott Allison , Parimi Prabhu S. , Gaetano Lisa , Merhar Stephanie L. , Schibler Kurt , Poindexter Brenda B. , Kim Jae , Yolton Kimberly , Cahill Tanya E. , Russell David , Dudley Juanita , Gratton Teresa L. , Grisby Cathy , Henkes Lisa , Kirker Kristin , Stacey Sara , Wuertz Sandra , Cotten C. Michael , Goldberg Ronald N. , Laughon Matthew M. , Goldstein Ricki F. , Malcolm William F. , Ashley Patricia L. , Mago-Shah Deesha , Finkle Joanne , Fisher Kimberley A. , Gustafson Kathryn E. , Bose Carl L. , Bernhardt Janice , Bose Gennie , Clark Cindy , Wereszczak Janice , Warner Diane , Talbert Jennifer , Kicklighter Stephen D. , Bentley Alexandra , Edwards Laura , Rhodes-Ryan Ginger , White Donna , Patel Ravi M. , Carlton David P. , Stoll Barbara J. , Loggins Yvonne , Adams-Chapman (deceased) Ira , Sewell Elizabeth , Maitre Nathalie , Bottcher Diane , Carter Sheena L. , Hale Ellen C. , Kendrick-Allwood Salathiel , Laursen Judith , Mulligan LaRossa Maureen , Mackie Colleen , Sanders Amy , Smikle Gloria , Wineski Lynn , Walsh Michele C. , Bremer Andrew A. , Higgins Rosemary D. , Wilson Archer Stephanie , Sokol Gregory M. , Papile Lu-Ann , Herron Dianne E. , Hines Abbey C. , Lytle Carolyn , Smiley Lucy , Wilson Leslie Dawn , Watkins Donna , Gunn Susan , Joyce (deceased) Jeff , Tyson Jon E. , Khan Amir M. , Kennedy Kathleen A. , Rysavy Matthew A. , Mosquera Ricardo A. , Eason Elizabeth , Stephens Emily , Alaniz Nora I. , Allain Elizabeth , Arldt-McAlister Julie , Boricha Fatima , Burson Katrina , Dempsey Allison G. , Garcia Carmen , Hall Donna J. , John Janice , Jones Patrick M. , Lillie M. Layne , Mason Carrie M. , Martin Karen , Martin Sara C. , McDavid Georgia E. , McKee Shannon L. , Poe Michelle , Rennie Kimberly , Reddy Tina , Rodgers Shawna , Khan Siddiki Saba , Sperry Daniel , Pierce Tate Patti L. , White Michelle , Wright Sharon L. , Zanger Dinorah , Sánchez Pablo J. , Slaughter Jonathan L.. , Nelin Leif D. , Jadcherla Sudarshan R. , Maitre Nathalie L. , Timan Christopher , Yeates Keith O. , Luzader Patricia , Batterson Nancy , Baugher Hallie , Beckford Demi R. , Burkhardt Stephanie , Carey Helen , Chao Michelle , Cira Courtney , Clark Erna , DeSantis Brittany , Fortney Christine A. , Fowler Aubrey , Gutentag Julie , Grothause Jennifer L. , Hague Cole D. , Keim Sarah A. , Levengood Katelyn , Marzec Laura , McCool Jacqueline , Miller Bethany , Nelin Mary Ann , Newton Julia , Park Courtney , Pietruszewski Lindsay , Purnell Jessica , Seabrook Ruth , Shadd Julie C. , Small Kristi , Stein Melanie , Sullivan Margaret , Sullivan Rox Ann , Warnimont Kyrstin , Yossef-Salameh Lina , Fearns Erin , Das Abhik , Gantz Marie G. , Wiener Laura Elizabeth , Wallace Dennis , O’Donnell Auman Jeanette , Crawford Margaret , Gabrio Jenna , Newman Jamie E. , Parlberg Lindsay , Petrie Huitema Carolyn M. , Zaterka-Baxter Kristin M. , Van Meurs Krisa P. , Chock Valerie Y. , Stevenson David K. , Ball M. Bethany , Bahmani Dona , Adams Marian M. , Bentley Barbara , DeAnda Maria Elena , DeBattista Anne M. , Earhart Beth , Huffman Lynne C. , Krueger Casey E. , Lucash Ryan E. , Proud Melinda S. , Reichert Elizabeth N. , Taylor Heather , Weiss Hali E. , Williams R. Jordan , Ambalavanan Namasivayam , Peralta-Carcelen Myriam , Collins Monica V. , Cosby Shirley S. , Bailey Kirstin J. , Biasini Fred J. , Chopko Stephanie A. , Domnanovich Kristy A. , Jno-Finn Chantel J. , Ladinsky Morissa , Moses Mary Beth , Buie Cindie , McNair Tara E. , Phillips Vivien A. , Preskitt Julie , Rector Richard V. , Stringer Kimberlly , Whitley Sally , York Chapman Sheree , Devaskar Uday , Garg Meena , Purdy Isabell B. , Chanlaw Teresa , Geller Rachel , Colaizy Tarah T. , Widness John A. , Johnson Karen J. , Eastman Diane L. , Walker Jacky R. , Goeke Claire A. , Schmelzel Mendi L. , Faruqui Sarah E. , Coulter Brenda J. , Schrimper Bailey M. , Jellison Sydney S. , Knosp Laura K. , Arnold Sandra J. , Andrews Haley A. , Ellsbury Dan L. , Bass Donia B. , Tud Tracy L. , Baack Michelle L. , Richards Laurie A. , Henning Megan M. , Elenkiwich Chelsey , Broadbent Megan , Van Muyden Sarah , Brodkorb Aimee T. , Watterberg Kristi L. , Fuller Janell , Ohls Robin K. , Backstrom Lacy Conra , Hartenberger Carol , Sundquist Beauman Sandra , Hanson Mary , Lowe Jean R. , Kuan Elizabeth , DeMauro Sara B. , Eichenwald Eric C. , Schmidt Barbara , Kirpalani Haresh , Abbasi Soraya , Chaudhary Aasma S. , Mancini Toni , Cucinotta Dara M. , Bernbaum Judy C. , Gerdes Marsha , Ghavam Savin , Hurt Hallam , Snyder Jonathan , Ziolkowski Kristina , Dhawan Megan , Booth Lauren , Catts Christine , D'Angio Carl T. , Guillet Ronnie , Myers Gary J. , Reynolds Anne Marie , Lakshminrusimha Satyan , Wadkins Holly I.M. , Sacilowski Michael G. , Jensen Rosemary L. , Merzbach Joan , Zorn William , Farooq Osman , Maffett Dee , Williams Ashley , Hunn Julianne , Guilford Stephanie , Yost Kelley , Rowan Mary , Prinzing Diane , Bowman Melissa , Reubens Linda J. , Scorsone Ann Marie , Harley-McAndrew Michelle , Fallone Caitlin , Binion Kyle , Orme Constance , Sabaratnam Premini , Kent Alison , Jones Rachel , Boylin Elizabeth , Rochez Daisy , Li Emily , Kachelmeyer Jennifer , McKee Kimberly G. , Coleman Kelly R. , Moreland Melissa , Cavanaugh Brenna , Wyckoff Myra H. , Brion Luc P. , Heyne Roy J. , Vasil Diana M. , Adams Sally S. , Chen Lijun , De Leon Maria M. , Duran JoAnne , Eubanks Frances , McDougald Rebecca , Pavageau Lara , Sepulveda Pollieanna , Guzman Alicia , Harrod Michelle , Heyne Elizabeth , Madden Linda A. , Lee Lizette E. , Puentez Anna , Tolentino-Plata Kristine , Twell Boatman Cathy , Vera Azucena , Waterbury Jillian , Yoder Bradley A. , Baserga Mariana , Faix Roger G. , Minton Stephen D. , Sheffield Mark J. , Rau Carrie A. , Baker Shawna , Burnett Jill , Christensen Susan , Cole Bledsoe Laura , Cunningham Sean D. , Davis Brandy , Elmont Jennifer O. , Hall Becky , Jensen Erika R. , Loertscher Manndi C. , Marchant Trisha , Maxson Earl , McGrath Kandace M. , Mickelsen Hena G. , Morshedzadeh Galina , Parry D. Melody , Reich Brixen A. , Schaefer Susan T. , Stout Kelly , Stuart Ashley L. , Weaver-Lewis Kimberlee , Winter Sarah , Woodbury Kathryn D. , Osborne Karen , Bird Karie , Coleman Kathleen , Francom Barbara L. , Jordan Jamie , Steffen Mike , Tice Katherine , Shankaran Seetha , Natarajan Girija , Pappas Athina , Sood Beena G. , Bajaj Monika , February Melissa , Agarwal Prashant , Chawla Sanjay , Bara Rebecca , Childs Kirsten , Woldt Eunice , Goldston Laura , Wiggins Stephanie A. , Christensen Mary K. , Carlson Martha , Barks John , White Diane F. 
Published: March 2024

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.