Abstract
IMPORTANCE: Minoritized racial and ethnic groups, such as American Indian and Black individuals, often receive lower quality health care compared with White individuals. There is limited understanding of how these disparities extend to obstetric care, particularly when comparing the quality of care at the actual delivery hospital vs the nearest obstetric hospital based on the birthing individual's residence. OBJECTIVE: To examine inequality in care based on the actual delivery hospital and the closest delivery hospital to the birthing individual's residential zip code centroid. DESIGN, SETTING, AND PARTICIPANTS: This population-based retrospective cohort study used data from 5 states (2008 to 2020 for Michigan, Oregon, and South Carolina; 2008 to 2018 for Pennsylvania; and 2008 to 2012 for California). Individuals delivering a fetal death or a live birth with gestational age between 22 to 44 weeks were included. Analysis was conducted between February and August 2024. EXPOSURE: Race and ethnicity. MAIN OUTCOMES AND MEASURES: The obstetric inequality index was calculated using Gini coefficients from Lorenz curves for American Indian, Asian, Black, and Hispanic birthing individuals compared with White individuals, with hospitals ranked by their standardized morbidity ratio for nontransfusion severe maternal morbidity. RESULTS: There were 6 418 635 birthing individuals across 549 hospitals (23 050 American Indian individuals [0.4%], 463 342 Asian individuals [7.2%], 807 738 Black individuals [12.6%], 1 645 922 Hispanic individuals [25.6%], and 3 279 315 White individuals [51.1%]). Compared with White individuals, American Indian and Black individuals delivered at lower-quality hospitals, while there was no significant difference for Asian and Hispanic individuals (delivery hospital inequality index: American Indian, 0.07 [95% CI, 0.03 to 0.11]; Asian, -0.02 [95% CI, -0.08 to 0.04]; Black, 0.15 [95% CI, 0.12 to 0.19]; Hispanic -0.04 [95% CI, -0.09 to 0.01]). Black individuals lived closer to lower-quality hospitals than White individuals (closest hospital inequality index for Black individuals: 0.11 [95% CI, 0.07 to 0.14]). Asian and Hispanic individuals had similar closest hospital inequality indices to White individuals. The inequality index for Black individuals would have been lower if individuals had delivered at their nearest hospital. CONCLUSIONS AND RELEVANCE: This cohort study found that American Indian and Black individuals delivered at lower-quality hospitals than White individuals. The disparity in care between Black and White birthing individuals would have been reduced if individuals had delivered at their nearest hospital.