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Original Investigation
March 25, 2019

Racial Segregation and Inequality in the Neonatal Intensive Care Unit for Very Low-Birth-Weight and Very Preterm Infants

Author Affiliations
  • 1Vermont Oxford Network, Burlington
  • 2Department of Pediatrics, Robert Larner MD College of Medicine, University of Vermont, Burlington
  • 3Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, University of Vermont, Burlington
  • 4Perinatal Epidemiology and Health Outcomes Research Unit, School of Medicine, Division of Neonatology, Department of Pediatrics, Stanford University, Lucile Packard Children’s Hospital, Palo Alto, California
  • 5California Perinatal Quality Care Collaborative, Palo Alto
  • 6Department of Statistics, Baskin School of Engineering, University of California, Santa Cruz, Santa Cruz
  • 7Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 8Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia
  • 9Health Economics Resource Center and Center for Implementation to Innovation, Veterans Affairs Palo Alto Healthcare System, Menlo Park, California
  • 10Department of Health Policy and Administration, Pennsylvania State University, State College
  • 11Department of Sociology and Criminology, Pennsylvania State University, State College
JAMA Pediatr. 2019;173(5):455-461. doi:10.1001/jamapediatrics.2019.0241
Key Points

Question  What is the extent of segregation and inequality in neonatal intensive care units (NICUs)?

Findings  A cohort study of 117 982 very low-birth-weight and very preterm infants found that NICUs were segregated by race and ethnicity. Compared with white infants, black infants were concentrated at lower-quality NICUs and Hispanic and Asian infants at higher-quality NICUs.

Meaning  Segregation explains where infants receive care but not why black infants receive care at lower-quality NICUs and Asian infants receive care at higher-quality NICUs than white infants.


Importance  Racial and ethnic minorities receive lower-quality health care than white non-Hispanic individuals in the United States. Where minority infants receive care and the role that may play in the quality of care received is unclear.

Objective  To determine the extent of segregation and inequality of care of very low-birth-weight and very preterm infants across neonatal intensive care units (NICUs) in the United States.

Design, Setting, and Participants  This cohort study of 743 NICUs in the Vermont Oxford Network included 117 982 black, Hispanic, Asian, and white infants born at 401 g to 1500 g or 22 to 29 weeks’ gestation from January 2014 to December 2016. Analysis began January 2018.

Main Outcomes and Measures  The NICU segregation index and NICU inequality index were calculated at the hospital level as the Gini coefficients associated with the Lorenz curves for black, Hispanic, and Asian infants compared with white infants, with NICUs ranked by proportion of white infants for the NICU segregation index and by composite Baby-MONITOR (Measure of Neonatal Intensive Care Outcomes Research) score for the NICU inequality index.

Results  Infants (36 359 black [31%], 21 808 Hispanic [18%], 5920 Asian [5%], and 53 895 white [46%]) were segregated among the 743 NICUs by race and ethnicity (NICU segregation index: black: 0.50 [95% CI, 0.46-0.53], Hispanic: 0.58 [95% CI, 0.54-0.61], and Asian: 0.45 [95% CI, 0.40-0.50]). Compared with white infants, black infants were concentrated at NICUs with lower-quality scores, and Hispanic and Asian infants were concentrated at NICUs with higher-quality scores (NICU inequality index: black: 0.07 [95% CI, 0.02-0.13], Hispanic: −0.10 [95% CI, −0.17 to −0.04], and Asian: −0.26 [95% CI, −0.32 to −0.19]). There was marked variation among the census regions in weighted mean NICU quality scores (range: −0.69 to 0.85). Region of residence explained the observed inequality for Hispanic infants but not for black or Asian infants.

Conclusions and Relevance  Black, Hispanic, and Asian infants were segregated across NICUs, reflecting the racial segregation of minority populations in the United States. There were large differences between geographic regions in NICU quality. After accounting for these differences, compared with white infants, Asian infants received care at higher-quality NICUs and black infants, at lower-quality NICUs. Explaining these patterns will require understanding the effects of sociodemographic factors and public policies on hospital quality, access, and choice for minority women and their infants.