Delays in postpartum hemorrhage interventions by race and maternal morbidity
Catherine Yang, Sydney Seignious, Sahel Hazrati, Janeva Dimen, Mohammad Sunoqrot, Ahizechukwu C. Eke, Jerome J. Federspiel, Victoria R. Greenberg, Jaclyn M. Phillips, Emily R. Smith, Courtney D. Townsel, Arthur J. Vaught, Lisa C. Zuckerwise, Homa K. AhmadziaAbstract
Objective
Non‐White patients experience higher rates of postpartum hemorrhage (PPH) as well as associated morbidity and mortality compared to White counterparts. This study examined whether delays in intervention in patients with PPH varied by patient race and insurance status and whether delays were associated with increased morbidity.
Methods
We conducted a retrospective cohort study of patients with PPH (total blood loss ≥ 1000 mL) in a large health system between 2019 and 2024 using electronic medical record data. The primary exposure was patient race (White, Black, and Asian). The primary outcome was time to PPH interventions. The secondary outcome was maternal morbidity as a composite of severe PPH (defined as blood loss greater than 1500 mL), blood product transfusion, intensive care unit (ICU) transfer, or hysterectomy. Unadjusted analyses of intervention timing were performed using type 2, two‐tailed t ‐tests. After adjusting for gestational age, anemia, and delivery mode, analyses of associations between maternal morbidity and time to intervention were computed using binary logistic regression. Kaplan–Meier curves were generated to compare the cumulative maternal morbidity between racial and insurance groups.
Results
A total of 4316 patients were included, of which 13% were Black ( n = 587), 8% were Asian ( n = 356), and 6% ( n = 289) were publicly insured. Asian patients underwent balloon tamponade (229 vs. 87 min, p < 0.001) and uterine artery embolization (477 vs. 258 min, p = 0.005) later than White patients. Compared to White patients, Asian patients had increased odds of maternal morbidity (adjusted odds ratio [aOR], 1.66; 95% confidence interval [CI], 1.28–2.15). Kaplan–Meier curves demonstrated a lower probability of remaining morbidity‐free over time compared with those receiving intervention earlier. Additionally, significant differences were noted in time to intervention between White, Black, and Asian patients for medication ( p = 0.024) and uterine balloon tamponade ( p = 0.021) but not uterine artery embolization ( p = 0.141) or hysterectomy ( p = 0.948).
Conclusion
This study suggests that Asian patients experience delays to PPH care escalation as well as increased odds of maternal morbidity. This finding highlights the need for standardized PPH protocols and further research on the optimal timing of invasive interventions as well as structural factors contributing to unequal care.