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 sought to estimate the effects of race and rural-urban status on cardiac-specific severe maternal morbidity ("cardiac SMM") in North Carolina.

Methods: This retrospective study used the 2019 North Carolina State Inpatient Database (SID). Diagnosis codes were used to identify births, 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 SMM.

Results: Of 106,778 births, 369 had mWHO category I-II disease, and 366 had mWHO category II/III-IV disease. Individuals with cardiac disease had higher rates of cardiac SMM (10.4% versus 0.27% versus 0.13% for mWHO II/III-IV, mWHO I/II, and no disease, respectively). Among patients with mWHO II/III-IV disease, 60.0% of rural residents delivered at hospitals with advanced cardiac capabilities versus 80.8% of urban residents; there were no statistically significant differences in cardiac SMM rates (11.3% versus 10.1% for rural versus urban individuals, P = NS). In contrast, there were pronounced disparities in cardiac SMM among Black individuals compared with White individuals (0.28% versus 0.13%, P < .001), especially among individuals with mWHO II/III-IV disease (23.71% versus 5.41%, P < .001).

Limitations: Cardiac disease and outcomes were identified based on diagnosis and procedure codes. Identifying complications subsequent to the delivery hospitalization was not possible.

Conclusions: In North Carolina, there is a pronounced racial disparity in cardiac SMM during delivery hospitalizations, which is driven by patients with mWHO II/III-IV disease.