Racial and Rural-Urban Disparities in Maternal Cardiac Disease Care in North Carolina: A Call to Action

Background: Cardiac disease is a leading cause of severe maternal morbidity (SMM). We investigated deliveries among North Carolina individuals with preexisting heart disease and assessed outcomes by race and rural-urban status. Methods: This retrospective study used the 2019 North Carolina State Inpatient Database (SID). Diagnosis codes were used to identify deliveries, comorbidities, modified World Health Organization (mWHO) cardiac category, and outcomes. Hospital-level data were obtained from publicly-available sources and the SID datasets. The primary outcome was a composite of cardiac-specific severe maternal morbidity (“cSMM”). Results: Of 106,778 delivery hospitalizations, 369 had mWHO category I-II disease, and 366 had mWHO category II/III-IV disease. Individuals with cardiac disease had higher rates of cSMM (10.4% vs. 0.27% vs. 0.13% for mWHO II/III-IV, mWHO I/II, and no disease, respectively). Among patients with mWHO II/III-IV disease, 60.0% rural-living patients delivered at hospitals with advanced cardiac capabilities versus 80.8% of urban-living patients; there were no statistically-significant differences in cSMM rates (11.3% vs. 10.1% for rural vs. urban patients, p=NS). In contrast, there were pronounced disparities in cSMM among Black patients compared with white patients (0.28% vs. 0.13%, p<0.001), which was concentrated among patients with mWHO II/III-IV disease (23.71% vs. 5.41%, p<0.001). Limitations: Cardiac disease and outcomes were identified based on billing codes, and identifying additional complications after the delivery hospitalization was not possible. Conclusions: In North Carolina, there is a pronounced racial disparity in cSMM during delivery hospitalizations, which is driven by patients with mWHO II/III-IV disease. These data also demonstrate a rural/urban disparity in the cardiac capabilities of hospitals delivering patients with mWHO II/III-IV disease.

Duke Scholars

Author Brenna L Hughes Obstetrics and Gynecology, Maternal Fetal Medicine

Author Maria Jacqueline Small Obstetrics and Gynecology, Maternal Fetal Medicine

Author Elizabeth Gresham Livingston Obstetrics and Gynecology, Maternal Fetal Medicine

Author Marie-Louise Meng Anesthesiology, Women's

Author Jerome Jeffrey Federspiel Obstetrics and Gynecology, Maternal Fetal Medicine