Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Published:

Disparity drivers, potential solutions, and the role of a health equity dashboard in the neonatal intensive care unit: a qualitative study

Journal of Perinatology (2023)Cite this article

Subjects

Abstract

Objective

Racial/ethnic disparities are well-described in the neonatal intensive care unit (NICU). We explored expert opinion on their etiology, potential solutions, and the ability of health equity dashboards to meaningfully capture NICU disparities.

Study design

We conducted 12 qualitative semi-structured interviews, purposively selecting a diverse group of neonatal experts. We used grounded theory to develop codes, shape interviews, and conduct analysis.

Result

We identified three sources of disparity: interpersonal bias, care process and institutional barriers, and social determinants of health, particularly as they affect parental engagement in the NICU. Proposed solutions included racial/cultural concordance, bolstering hospital-based resources, and policy interventions. Health equity dashboards were viewed as useful but limited, because clinical metrics do not account for many of the aforementioned sources of disparities.

Conclusion

Equity dashboards serve as a motivational starting point for quality improvement; future iterations may require novel, qualitative data sources to identify underlying etiologies of NICU disparities.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: Sample of California Perinatal Quality Care Collaborative Health Equity Dashboard.
Fig. 2: Etiologies of disparities in the NICU.

Similar content being viewed by others

Data availability

The datasets generated and analyzed during the current study are not publicly available due to the importance of maintaining anonymity of the research participants but are available from the corresponding author on reasonable request.

References

  1. Horbar JD, Edwards EM, Greenberg LT, Profit J, Draper D, Helkey D, et al. Racial segregation and inequality in the neonatal intensive care unit for very low-birth-weight and very preterm infants. JAMA Pediatr. 2019;173:455.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Wallace ME, Mendola P, Kim SS, Epps N, Chen Z, Smarr M, et al. Racial/ethnic differences in preterm perinatal outcomes. Am J Obstet Gynecol. 2017;216:306.e1–12.

    Article  PubMed  Google Scholar 

  3. Manuck TA. Racial and ethnic differences in preterm birth: a complex, multifactorial problem. Semin Perinatol. 2017;41:511–8.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Collins JW, David RJ, Handler A, Wall S, Andes S. Very low birthweight in african american infants: the role of maternal exposure to interpersonal racial discrimination. Am J Public Health. 2004;94:2132–8.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Witt RE, Malcolm M, Colvin BN, Gill MR, Ofori J, Roy S, et al. Racism and quality of neonatal intensive care: voices of black mothers. Pediatrics. 2022;150:e2022056971.

  6. Sigurdson K, Morton C, Mitchell B, Profit J. Disparities in NICU quality of care: a qualitative study of family and clinician accounts. J Perinatol. 2018;38:600–7.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Sigurdson K, Mitchell B, Liu J, Morton CH, Gould JB, Lee HC, et al. Racial/ethnic disparities in neonatal intensive care: a systematic review. Pediatrics. 2019;144:e20183114.

    Article  PubMed  Google Scholar 

  8. Barfield WD, Cox S, Henderson ZT. Disparities in neonatal intensive care: context matters. Pediatrics. 2019;144.

  9. Houston KL, Walker VP. “Is this mic on?” Improving NICU quality of care by amplifying black mothers’ voices. Pediatrics. 2022;150:e2022057436.

  10. Ravi D, Iacob A, Profit J. Unequal care: racial/ethnic disparities in neonatal intensive care delivery. Semin Perinatol. 2021;45:151411.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Ravi D, Profit J. Disparities in neonatal intensive care: causes, consequences and charting the path forward. Semin Perinatol. 2021;45:151406.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Ravi D, Sigurdson K, Profit J. Improving quality of care can mitigate persistent disparities. Pediatrics. 2019;144:e20192002.

  13. Montoya-Williams D, Fraiman YS, Peña MM, Burris HH, Pursley DM. Antiracism in the field of neonatology: a foundation and concrete approaches. Neoreviews. 2022;23:e1–12.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Reichman V, Brachio SS, Madu CR, Montoya-Williams D, Peña MM. Using rising tides to lift all boats: equity-focused quality improvement as a tool to reduce neonatal health disparities. Semin Fetal Neonatal Med. 2021;26:101198.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Thorpe LE, Gourevitch MN. Data dashboards for advancing health and equity: proving their promise? Am J Public Health. 2022;112:889–92.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Bilal U, McCulley E, Li R, Rollins H, Schnake-Mahl A, Mullachery PH, et al. Tracking COVID-19 inequities across jurisdictions represented in the Big Cities Health Coalition (BCHC): the COVID-19 health inequities in BCHC cities dashboard. Am J Public Health. 2022;112:904–12.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Backonja U, Park S, Kurre A, Yudelman H, Heindel S, Schultz M, et al. Supporting rural public health practice to address local-level social determinants of health across Northwest states: development of an interactive visualization dashboard. J Biomed Inf. 2022;129:104051.

    Article  Google Scholar 

  18. Gourevitch MN, Athens JK, Levine SE, Kleiman N, Thorpe LE. City-level measures of health, health determinants, and equity to foster population health improvement: the city health dashboard. Am J Public Health. 2019;109:585–92.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Arsenault C, Harper S, Nandi A, Rodríguez JM, Hansen PM, Johri M. An equity dashboard to monitor vaccination coverage. Bull World Health Organ. 2017;95:128–34.

    Article  PubMed  Google Scholar 

  20. Clarke A, Charmaz K. Grounded theory and situational analysis. London 2019. https://methods.sagepub.com/foundations/grounded-theory-and-situational-analysis.

  21. Marsh DR, Schroeder DG, Dearden KA, Sternin J, Sternin M. The power of positive deviance. BMJ. 2004;329:1177–9.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Sigurdson K, Profit J, Dhurjati R, Morton C, Scala M, Vernon L, et al. Former NICU families describe gaps in family-centered care. Qual Health Res. 2020;30:1861–75.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Brignoni-Pérez E, Scala M, Feldman HM, Marchman VA, Travis KE. Disparities in Kangaroo Care for premature infants in the neonatal intensive care unit. J Dev Behav Pediatr. 2022;43:e304–11.

    Article  PubMed  Google Scholar 

  24. Scala M, Seo S, Lee-Park J, McClure C, Scala M, Palafoutas JJ, et al. Effect of reading to preterm infants on measures of cardiorespiratory stability in the neonatal intensive care unit. J Perinatol. 2018;38:1536–41.

    Article  PubMed  Google Scholar 

  25. Franck LS, O’Brien K. The evolution of family-centered care: from supporting parent-delivered interventions to a model of family integrated care. Birth Defects Res. 2019;111:1044–59.

    Article  CAS  PubMed  Google Scholar 

  26. Fraiman YS, Stewart JE, Litt JS. Race, language, and neighborhood predict high-risk preterm Infant Follow Up Program participation. J Perinatol. 2022;42:217–22.

    Article  PubMed  Google Scholar 

  27. Dhurjati R, Sigurdson K, Profit J. Patient- and family-centered care as a dimension of quality. Am J Med Qual. 2019;34:307–8.

    Article  PubMed  Google Scholar 

  28. Davidson JE, Aslakson RA, Long AC, Puntillo KA, Kross EK, Hart J, et al. Guidelines for family-centered care in the neonatal, pediatric, and adult ICU. Crit Care Med. 2017;45:103–28.

    Article  PubMed  Google Scholar 

  29. Cooper LG, Gooding JS, Gallagher J, Sternesky L, Ledsky R, Berns SD. Impact of a family-centered care initiative on NICU care, staff and families. J Perinatol. 2007;27:S32–7.

    Article  PubMed  Google Scholar 

  30. Unaka NIHM, Hsu J, Dardess P, Casillas CT, Fanta M, Dokken DL, et al. The intersection of diversity, equity, and inclusion with pediatric patient and family advisory councils. Patient Exp J. 2022;9:39–54.

    Article  Google Scholar 

  31. Janevic T, Zeitlin J, Egorova NN, Hebert P, Balbierz A, Stroustrup AM, et al. Racial and economic neighborhood segregation, site of delivery, and morbidity and mortality in neonates born very preterm. J Pediatr. 2021;235:116–23.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Padula AM, Shariff-Marco S, Yang J, Jain J, Liu J, Conroy SM, et al. Multilevel social factors and NICU quality of care in California. J Perinatol. 2021;41:404–12.

    Article  PubMed  Google Scholar 

  33. Burris HH, Hacker MR. Birth outcome racial disparities: a result of intersecting social and environmental factors. Semin Perinatol. 2017;41:360–6.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Murosko DC, Peña MM, Lorch SA. Racial and ethnic disparities in outcomes after NICU discharge: an equity-focused model. Semin Perinatol. 2022;46:151659.

    Article  PubMed  Google Scholar 

  35. Profit J, Edwards EM, Pursley D. Getting to health equity in NICU care in the USA and beyond. Arch Dis Child Fetal Neonatal Ed. 2023;108:326–31.

  36. Fraiman YS, Cheston CC, Morales D, Leeman KT, Hansen AR. A mixed methods study of perceptions of bias among neonatal intensive care unit staff. Pediatr Res. 2023;93:1672–8.

Download references

Acknowledgements

The authors wish to acknowledge Briana Mitchell, RN, for her assistance in performing the interviews.

Funding

This work was supported by funding from the National Institute of Health, grant 1R01HD083368.

Author information

Authors and Affiliations

  1. Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA

    Sheila Razdan, Laura C. Hedli, Jochen Profit & Christine H. Morton

  2. School of Journalism, Writing, and Media, University of British Columbia, Kelowna, BC, Canada

    Krista Sigurdson

Authors
  1. Sheila Razdan
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Laura C. Hedli
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Krista Sigurdson
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jochen Profit
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Christine H. Morton
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

SR and LH performed the data analysis and interpretation and drafted the initial manuscript. KS contributed to the conception of the work, recruited participants, coordinated data collection, and revised the manuscript critically for important intellectual content. JP contributed to the conception of the work, consulted on data collection instruments, and revised the manuscript critically for important intellectual content. CHM conceptualized and designed the study, designed the data collection instruments, recruited participants, coordinated and supervised data collection, supervised data interpretation, and revised the manuscript critically for important intellectual content. All authors gave final approval of the version to be published and are in agreement to be accountable for all aspects of the work.

Corresponding author

Correspondence to Christine H. Morton.

Ethics declarations

Competing interests

JP and CHM’s work has been funded by the NIH. SR, LCH, and KS declare no potential competing interests.

Ethics approval and consent to participate

This study was approved by the Institutional Review Board at Stanford University (reference number eProtocol #35418). Informed consent and consent for publication was obtained from each study participant. The study was performed in accordance with the Declaration of Helsinki.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Razdan, S., Hedli, L.C., Sigurdson, K. et al. Disparity drivers, potential solutions, and the role of a health equity dashboard in the neonatal intensive care unit: a qualitative study. J Perinatol (2023). https://doi.org/10.1038/s41372-023-01856-5

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1038/s41372-023-01856-5

Search

Advanced search

Quick links