Racial Disparities in Care Escalation for Postpartum Hemorrhage Requiring Transfusion.

BACKGROUND: Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality in the U.S. and disproportionately affects pregnant persons of color.

OBJECTIVE: The objective of this study was to identify the demographic and obstetric characteristics of those who received different levels of antihemorrhagic intervention in the setting of severe PPH requiring blood transfusion.

STUDY DESIGN: We conducted a retrospective cohort study of patients with documented PPH (estimated blood loss [EBL] of ≥1000mL) and blood product transfusion. We defined 3 levels of antihemorrhagic intervention: (Level 1) administration of uterotonics only, (Level 2) performance of a procedure (i.e., B-Lynch suture, O'Leary stitch, Bakri balloon, dilation and curettage, laceration repair, or embolization), and (Level 3) hysterectomy. Maternal demographics, obstetric characteristics, and comorbidities were extracted from electronic health records. Ordinal logistic regression was used to estimate the odds of higher intervention level adjusting for maternal demographic and obstetric characteristics.

RESULTS: 365 patients were included in this study, with a racial-ethnic composition of 30% White, 42% Black, 18% Hispanic, and 10% Other. 64% (n=233) received Level 1 intervention, 27% (n=98) received Level 2 intervention, and 9% (n=34) received Level 3 intervention. Patients receiving higher levels of intervention were more likely to have greater EBL (p<0.001), more transfusions (p<0.001), and be of advanced maternal age (p=0.004). Compared to White patients, Black and Hispanic patients were less likely to have received higher levels of intervention (p=0.034). After adjusting for EBL, advanced maternal age, placenta accreta spectrum, and fibroids, Black patients remained significantly less likely to receive higher levels of intervention (aOR 0.55, 95% CI 0.30-0.98). This difference persisted at EBL ≥ 3000mL, with Black and Hispanic patients being significantly less likely to receive higher levels of intervention compared to White patients (OR 0.31, 95% CI 0.10-0.92 and OR 0.10, 95% CI 0.01-0.53 respectively).

CONCLUSION: Among patients experiencing PPH and receiving transfusion, Black patients are less likely to receive higher levels of antihemorrhagic intervention. This disparity is concerning in this high-risk population and requires further attention and investigation.