de Jongh et al.

BMC Pregnancy and Childbirth 2012, 12:97

http://www.biomedcentral.com/1471-2393/12/97

RESEARCH ARTICLE Open Access

The differential effects of maternal age,

race/ethnicity and insurance on neonatal
intensive care unit admission rates
Beatriz E de Jongh1,5*†, Robert Locke2,3†, David A Paul2,3† and Matthew Hoffman4†

Abstract
Background: Maternal race/ethnicity, age, and socioeconomic status (SES) are important factors determining birth
outcome. Previous studies have demonstrated that, teenagers, and mothers with advanced maternal age (AMA),
and Black/Non-Hispanic race/ethnicity can independently increase the risk for a poor pregnancy outcome. Similarly,
public insurance has been associated with suboptimal health outcomes. The interaction and impact on the risk of a
pregnancy resulting in a NICU admission has not been studied. Our aim was, to analyze the simultaneous
interactions of teen/advanced maternal age (AMA), race/ethnicity and socioeconomic status on the odds of NICU
admission.
Methods: The Consortium of Safe Labor Database (subset of n = 167,160 live births) was used to determine NICU
admission and maternal factors: age, race/ethnicity, insurance, previous c-section, and gestational age.
Results: AMA mothers were more likely than teenaged mothers to have a pregnancy result in a NICU admission.
Black/Non-Hispanic mothers with private insurance had increased odds for NICU admission. This is in contrast to
the lower odds of NICU admission seen with Hispanic and White/Non-Hispanic pregnancies with private insurance.
Conclusions: Private insurance is protective against a pregnancy resulting in a NICU admission for Hispanic and
White/Non-Hispanic mothers, but not for Black/Non-Hispanic mothers. The health disparity seen between Black and
White/Non-Hispanics for the risk of NICU admission is most evident among pregnancies covered by private
insurance. These study findings demonstrate that adverse pregnancy outcomes are mitigated differently across race,
maternal age, and insurance status.

Background view of aging as a “weathering” process. This hypothesis

Maternal race/ethnicity, age, and socioeconomic status captures the ways in which social inequality may affect
(SES) are important factors determining birth outcome the health of population groups differentially and the
[1-3]. Previous studies have demonstrated that, teen- ways in which these differences may be compounded by
agers, and mothers with advanced maternal age (AMA), age; reflective of the life circumstances that promote or
and Black/Non-Hispanic race/ethnicity can independ- undermine women’s health on a population level in ways
ently increase the risk for a poor pregnancy outcome. that can affect reproduction [4].
Similarly, public insurance has been associated with sub- Similarly, a stress model has been proposed to explain
optimal health outcomes. the elevated risk of an adverse pregnancy outcome.
Widening neonatal mortality racial disparities with ad- “Stress age” is synonymous with the concepts of weath-
vancing maternal age is consistent with a theoretical ering and altered allostatic loads. The stress-age model
proposes a linkage between altered birth outcomes
* Correspondence: [email protected] through combined effect of chronic medical conditions
†
Equal contributors
1
Department of Neonatal-Perinatal Medicine, St. Christopher’s Hospital for and persistent exposure to stress, including racism-
Children, Philadelphia, PA, USA associated stress [5]. Despite the fact that many well-
5
Division of Neonatal-Perinatal Medicine, St. Christopher’s Hospital for educated black women obtain prenatal care beginning in
Children, Philadelphia, PA, USA
Full list of author information is available at the end of the article

© 2012 de Jongh et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
de Jongh et al. BMC Pregnancy and Childbirth 2012, 12:97 Page 2 of 6
http://www.biomedcentral.com/1471-2393/12/97

the first trimester, the relative risk of death among their generalized linear models. There were no meaningful re-
offspring has increased over time [6]. sult differences whether logistic regression or general-
This study analyzes the comparative risk of a preg- ized linear models were utilized.
nancy resulting in a newborn being admitted to the
neonatal intensive care unit based upon the interaction
of maternal age, race/ethnicity, and insurance status. Results
We hypothesized that the risk of NICU admission for The study sample included 167,160 live births with
teenage mothers and mothers of advanced maternal age demographic information by age groups presented in
are inconsistently experienced by different maternal Table 1. When analyzing the study population by age,
race/ethnicities regardless of socioeconomic status. advanced maternal age mothers were more likely to have
a pregnancy result in a NICU admission (Figure 1).
White/Non-Hispanic and Hispanic mothers had similar
Methods patterns of NICU admission rates with high rates of
The Consortium of Safe Labor Database (CSLD: n = 233844 NICU admission with teenage pregnancies and advanced
mothers; 19 US hospitals 2002–2008) was used to determine maternal age. By contrast, Black/Non-Hispanic mothers
NICU admission and maternal factors: age, race/ethnicity had significantly higher rates with advanced age com-
(defined by maternal self-report), private vs. public insur- pared to teenage and intermediately aged mothers.
ance, previous history of cesarean section, and infant birth When stratifying for maternal age, race/ethnicity, and
gestational age. Maternal age was divided into three age insurance status, there was a divergent pattern to the
groups; teenage defined as a maternal age between 13 odds of an infant being admitted to the NICU that was
and 18 years old, followed by an intermediate age group dependent upon an interaction of race/ethnicity, age,
between 19 and 34 years old and an advanced maternal and insurance status (Figure 2). Private insurance was
age group defined as 35 to 49 years of age. Similar age associated with decreased odds of NICU admission be-
group distributions have been used by other authors [7,8]. tween Hispanic and White/Non-Hispanic infants. In
Analysis was performed between three self-reported ma- contrast, Black/Non-Hispanic mothers with private in-
ternal race/ethnicity descriptions (White/Non-Hispanic, surance had increased odds of a pregnancy resulting in a
Black/Non-Hispanic and Hispanic) and controlled for per- NICU admission (Table 2). Public insurance was asso-
centage of births by maternal age, maternal insurance ciated with increased odds of NICU admission of the
status, and history of previous cesarean section (c-section). White/Non-Hispanic and Hispanic population for all
To reflect the overall U.S. obstetric population, the three age groups. The Black/Non-Hispanic population
Consortium of Safe Labor assigned a weight to each with public insurance had lower odds of NICU admis-
mother based on the ACOG district, maternal race/eth- sion in the teenage and intermediate age group popula-
nicity, parity and plurality. tions than those on private insurance (Table 3). The
The Internal Review Board of Christiana Care Health disparity between Black/Non-Hispanic compared to the
System approved this study. Permission was granted by White/Non-Hispanic or Hispanic groups was greatest in
the Consortium of Safe Labor to use the information in the private insurance group.
the database. In each age group, Black/Non-Hispanic pregnancies
For mothers who had several pregnancies during the with public insurance were less likely to result in a
CSLD data acquisition time period, a mother was NICU admission than White/Non-Hispanic pregnancies
included only once in the analysis. For multiple gestation (Table 4). Among women with public insurance,
pregnancies, only the first infant was utilized for NICU advanced maternal age was associated with higher odds
admission. Women with race/ethnicity different than the of NICU admission between White/Non-Hispanic and
above criteria or with incomplete information were Black/Non-Hispanics compared to the middle age and
excluded from the analysis. Data were analyzed utilizing teenage maternal population. Among women with

Table 1 Patient population demographics stratified by age

Age (years) Within age group (%)
Race/Ethnicity NICU admission Insurance Previous C-section
White/Non-Hispanic Black/Non-Hispanic Hispanic Yes Private Yes
14 -18 39.7 28.5 31.8 15.0 28.7 2.1
19 – 34 64.4 14.7 20.9 13.8 59.0 14.7
35 – 49 70.8 11.5 17.8 16.3 78.8 26.2
de Jongh et al. BMC Pregnancy and Childbirth 2012, 12:97 Page 3 of 6
http://www.biomedcentral.com/1471-2393/12/97

would potentially be admitted to the regular newborn nur-

sery the results remain the same.

Discussion
The main finding of our investigation is that private insur-
ance did not benefit all race/ethnicity groups equally. Spe-
cifically, having private insurance did not protect Black/
Non-Hispanic mothers. Black/Non-Hispanic mothers with
private insurance had higher NICU admission odds
among teenagers and intermediate group women than
age-matched women with public insurance. From our data
we can not determine whether our findings directly
resulted from differences in health care provision based
on insurance or whether insurance was a proxy for other
important factors including absence of poverty. We specu-
late that the etiology of the paradoxical relationship of
higher NICU admission odds among Black/Non-Hispanics
Figure 1 Percentage of births of each maternal age and
with private insurance compared to public insurance is
race/ethnicity group admitted to the NICU.
likely secondary to ecological experiences, which adversely
affect the mother and are potentially exacerbated by
private insurance Hispanic and White/Non-Hispanics of higher socioeconomic status among certain minority
the teenage population had increased odds of NICU ad- groups. Our study is unique in investigating NICU admis-
mission compared to the AMA population (Table 5). sion, a variable indicative of physiologic instability of the
In order to investigate if the observed differential in newborn and a marker for long term health care
NICU admission was based on low gestation or utilization, in a large multicenter study sample.
physiologic compromise of older infants, we analyzed Our data suggest that among Black/Non-Hispanic
the data limiting gestation to infants ≥ 35 weeks. mothers, private health insurance, acting as a direct ef-
Infants < 35 weeks gestation are routinely admitted to fect or proxy, does not mitigate the adverse effects of
the NICU. Infants with gestational ages ≥ 35 weeks are life-course stressors. This finding is consistent with other
usually admitted for evidence of clinical compromise. studies demonstrating a lack of protective effect from
When limiting the data analysis by gestational age to improved neighborhood characteristics and income on
infants with a gestational age ≥ 35 weeks that, if healthy, Black/Non-Hispanic birth outcomes.

Figure 2 Percentage of births of each maternal age and race/ethnicity admitted to the NICU stratified by insurance status.
de Jongh et al. BMC Pregnancy and Childbirth 2012, 12:97 Page 4 of 6
http://www.biomedcentral.com/1471-2393/12/97

Table 2 NICU admission by maternal age and race, controlling for maternal insurance status and history of a previous
cesarean section
Maternal race Maternal age, insurance status and history of previous c-section Odds ratio 95% Confidence interval
White/Non- Hispanic 14 - 18 years old .964 (0.957 - 0.971)
19 - 34 years old 1
35–49 years old 1.256 (1.249 - 1.264)
Private insurance 1
Public insurance 1.788 (1.778 - 1.798)
No history of previous c-section 1
History of previous c-section 1.426 (1.417 - 1.435)
Black/Non-Hispanic 14 - 18 years old .935 (0.926 - 0.945)
19 - 34 years old 1
35 - 49 years old 1.476 (1.460 - 1.493)
Private insurance 1
Public insurance .944 (0.936 - 0.952)
No History of previous c-section 1
History of previous c-section 1.234 (1.219 - 1.248)
Hispanic 14 - 18 years old 1.175 (1.163 - 1.186)
19 - 34 years old 1
35 - 49 years old 1.204 (1.191 - 1.217)
Private insurance 1
Public insurance 1.354 (1.342 - 1.365)
No History of previous c-section 1
History of previous c-section 1.220 (1.206 - 1.234)

These findings are consistent with other literature that

shows a wider racial gap in poor birth outcomes among
women at seemingly lower risk. A stark racial disparity Table 4 OR of NICU admission by race/ethnicity, stratified
in the unadjusted rates of preterm birth and very low by age and iInsurance
birth weight exists among women with a lifelong resi- Age Race/ethnicity Insurance OR (± 95% CI)
for NICU admission
dence in high-income urban neighborhoods [9]. It has
Private Public
also been reported that the positive effects of a better
14-18 White/Non-Hispanic 1 1
Black/Non-Hispanic 1.46 0.85
Table 3 OR of NICU admission by insurance, stratified by (1.37 – 1.55) (0.82 – 0.89)
age and race/ethnicity
Hispanic 1.09 0.89
Age Race/ethnicity Insurance OR (± 95% CI)
for NICU admission (1.03 – 1.16) (0.86 – 0.92)
Private Public 19-34 White/Non-Hispanic 1 1
14-18 White/Non-Hispanic 1 1.37 (1.31 – 1.41) Black/Non-Hispanic 1.48 0.86
Black/Non-Hispanic 1 0.79 (0.75 – 0.83) (1.46-1.51) (0.85-0.88)
Hispanic 1 1.12 (1.06 – 1.18) Hispanic 0.85 0.70
19-34 White/Non-Hispanic 1 1.60 (1.58 – 1.61) (0.84 – 0.86) (0.69 – 0.71)
Black/Non-Hispanic 1 0.93 (0.913 – 0.947) 35-49 White/Non-Hispanic 1 1
Hispanic 1 1.33 (1.30 – 1.35) Black/Non-Hispanic 1.74 0.86
35-49 White/Non-Hispanic 1 2.37 (2.32 – 2.43) (1.69 – 1.78) (0.83 – 0.90)
Black/Non-Hispanic 1 1.13 (1.09 – 1.18) Hispanic 0.79 0.55
Hispanic 1 1.60 (1.54 – 1.66) (0.77 – 0.82) (0.53 – 0.57)
Controlled for history of previous c - section. Controlled for history of previous c-section.
de Jongh et al. BMC Pregnancy and Childbirth 2012, 12:97 Page 5 of 6
http://www.biomedcentral.com/1471-2393/12/97

Table 5 OR of NICU admission by age, stratified by United States have been shown to have favorable birth
insurance and race/ethnicity outcomes despite their social disadvantages. Proposed
Race/ethnicity Maternal Insurance OR (± 95% CI) explanations for this can be classified as migratory selec-
age for NICU admission tion processes, cultural protective factors, and increased
Private Public social support [13]. There was an increased risk of
White/Non-Hispanic 14 – 18 1.17 (1.12 – 1.22) 0.99 (0.97 – 1.02) NICU admission with AMA among Hispanic and
19 - 34 1 1 White/Non-Hispanic in the public insurance group that
35 - 49 1.04 (1.02 – 1.05) 1.54 (1.51 – 1.58) was not seen in the private insurance group. This sug-
Black/Non-Hispanic 14 – 18 1.15 (1.10 – 1.20) 0.97 (0.93 – 0.99)
gests that the “weathering hypothesis,” cumulative life
course stressors affecting later health, may apply to
19 - 34 1 1
White/Non-Hispanic and Hispanic mothers.
35 - 49 1.20 (1.17 – 1.24) 1.47 (1.41 – 1.52) The results of this study were obtained without control-
Hispanic 14 – 18 1.50 (1.43 – 1.58) 1.24 (1.20 – 1.27) ling for pregnancies conceived by assisted reproductive
19 - 34 1 1 technology. Of approximately 62 million women of repro-
35 - 49 0.97 (0.94 – 1.01) 1.18 (1.14 – 1.21) ductive age in 2002, about 1.2 million, or 2%, had had
Controlled for history of previous c-section. and infertility related medical appointment within the
previous year [14]. The risk of preterm birth is higher
socioeconomic context may be mitigated among minor- among infants conceived through assisted reproductive
ity women by adverse effects of racism or racial stigma technology than for infants in the general population.
[8]. In addition, Black/Non-Hispanic infants in hyper This increase in risk is due, in large part, to the higher
segregated areas are more likely to be preterm than in percentage of multiple-fetus pregnancies resulting from
non-hyper segregated areas [10]. Higher isolation has assisted reproductive technology cycles [14]. The influ-
also been associated with lower birth weight, higher ence of assisted reproductive technology would not be
rates of prematurity and higher rates of fetal growth re- able to fully explain the differences seen due to small per-
striction, in contrast with higher clustering being asso- centage of pregnancies conceived with this technology.
ciated with more optimal outcomes [7]. There are larger Our study has a number of important limitations. The
racial disparities among the non-poor than the poor in CSLD may not be generalizable to other populations.
the black population and among women than men [11]. This possibility was minimized as the database repre-
Controlling the analysis for gestational age or limiting sents 19 hospitals in the United States from wide geo-
the study population to gestational age ≥ 35 weeks did graphic regions and weighted to reflect national US
not alter our findings. The lack of influence of gesta- nativity. Maternal insurance status may not correlate ac-
tional age on the findings suggests that the increased curately with the actual socioeconomic level of each
odds of NICU admission in this population are related mother. There may have been other important factors
to factors independent of premature birth. We speculate influencing maternal health and wealth that we were un-
that Black/Non-Hispanic mothers with advanced age able to control for including maternal education level.
may have an increase in physiologic compromise that The study also did not account for institutional policies
goes beyond the known increase in premature birth. and clinical biases that may have influenced NICU ad-
These data are important in showing an increase in mission rates. We can not rule out the possibility that
NICU admission possibly secondary to concomitant Black/Non-Hispanic mothers were more likely to deliver
physiologic instability in infants born to Black/Non- an infant in hospitals where NICU admission was more
Hispanic women. The study data provide further sup- likely. In addition, we were only able to study insurance
port of the “weathering hypothesis,” adverse maternal status at the time of birth. Length of private insurance
health may be secondary to persistent life course stres- coverage may be an important factor in estimating its ef-
sors that are not modifiable, and in fact may be exacer- fect on maternal health.
bated, with private insurance at the time of childbirth. In our study, NICU admission was used as a primary
Hispanic women, when compared to the White/Non- outcome variable in order to investigate physiologic com-
Hispanic population, had decreased odds of NICU ad- promise and supplemental health care needs at birth.
mission in the intermediate and advanced maternal age NICU admissions are not restricted to extremely prema-
population for both private and public insurance. His- ture infants or infants with congenital anomalies. Late
panic women have lower odds for preterm birth com- preterm, term, and normal birthweight infants represent
pared to White/Non-Hispanic women. When compared a significant percentage of NICU admissions and NICU-
to African-American women, Hispanic women are less related health care costs [15]. In addition to the immedi-
likely than African-American women to experience any ate health cost burden, NICU admissions are associated
adverse pregnancy event [12]. Latina mothers in the with increased risk for altered school-age behavior and
de Jongh et al. BMC Pregnancy and Childbirth 2012, 12:97 Page 6 of 6
http://www.biomedcentral.com/1471-2393/12/97

achievement, accelerated development of health com- References

promise, and reduced economic potential when becom- 1. Schempf AH, Branum AM, Lukacs SL, Schoendorf KC: Maternal age and
parity-associated risks of preterm birth: differences by race/ethnicity.
ing an adult. The daily NICU costs exceed $ 3,500 per Paediatr Perinat Epidemiol 2007, 21(1):34–43.
infant, and it is not unusual for costs to top $ 1 million 2. Holzman C, Eyster J, Kleyn M, Messer LC, Kaufman JS, Laraia BA, O'Campo P,
for a prolonged stay [16]. The annual societal economic Burke JG, Culhane J, Elo IT: Maternal weathering and risk of preterm
delivery. Am J Public Health 2009, 99(10):1864–1871.
burden associated with preterm birth in the United 3. Love C, David RJ, Rankin KM, Collins JW Jr: Exploring weathering: effects of
States was at least $26.2 billion in 2005, or $51,600 per lifelong economic environment and maternal age on low birth weight,
infant born preterm [17]. small for gestational age, and preterm birth in African-American and
white women. Am J Epidemiol 2010, 172(2):127–134.
4. Geronimus AT: The weathering hypothesis and the health of African-
Conclusions American women and infants: evidence and speculations. Ethn Dis 1992,
These study findings demonstrate that adverse preg- 2(3):207–221.
5. Hogue CJ, Bremner JD: Stress model for research into preterm delivery
nancy outcomes are mitigated differently across race/ among black women. Am J Obstet Gynecol 2005, 192(5 Suppl):S47–55.
ethnicity, maternal age, and insurance status. Globally 6. Mathews TJ, Menacker F, MacDorman MF: Infant Mortality statistics from
addressing the issue of teenage pregnancy or advanced the 2001 period linked birth/infant death data set, vol. 52. CDC; 2003:1–28.
7. Bell JF, Zimmerman FJ, Almgren GR, Mayer JD, Huebner CE: Birth outcomes
maternal age, insurance status, race/ethnicity, without among urban African-American women: a multilevel analysis of the role
giving attention to the multi-layered interaction of these of racial residential segregation. Soc Sci Med 2006, 63(12):3030–3045.
variables may miss important differences in outcomes. 8. Pickett KE, Collins JW Jr, Masi CM, Wilkinson RG: The effects of racial
density and income incongruity on pregnancy outcomes. Soc Sci Med
Our data indicate that the factors influencing NICU ad- 2005, 60(10):2229–2238.
mission go beyond the narrowly defined scope of race/ 9. Collins JW Jr, David RJ, Simon DM, Prachand NG: Preterm birth among
ethnicity, insurance status and maternal age. Life experi- African American and white women with a lifelong residence in
high-income Chicago neighborhoods: an exploratory study. Ethn Dis
ences, underlying health status, and intergenerational 2007, 17(1):113–117.
effects of fetal and early childhood programming, are 10. Osypuk TL, Acevedo-Garcia D: Are racial disparities in preterm birth larger
potentially modifiable factors. Although expressed differ- in hypersegregated areas? Am J Epidemiol 2008, 167(11):1295–1304.
11. Geronimus AT, Hicken M, Keene D, Bound J: "Weathering" and age
ently, regardless of race/ethnicity, age, or income status, patterns of allostatic load scores among blacks and whites in the United
all mother-fetal/infant dyads are susceptible to adverse States. Am J Public Health 2006, 96(5):826–833.
pregnancy outcomes. Our study demonstrates that the 12. Brown HL, Chireau MV, Jallah Y, Howard D: The "Hispanic paradox": an
investigation of racial disparity in pregnancy outcomes at a tertiary care
complex interactions of race/ethnicity, insurance, and medical center. Am J Obstet Gynecol 2007, 197(2):197. e1; Aug-197.e7.
maternal age must be considered when planning pro- 13. McGlade MS, Saha S, Dahlstrom ME: The Latina paradox: an opportunity
grams to improve maternal health outcomes. for restructuring prenatal care delivery. Am J Public Health 2004,
94(12):2062–2065.
Abbreviations 14. CDC: 2009 Assisted Reproductive Technology, Success Rates: National Summary
NICU: Neonatal intensive care unit; AMA: Advanced maternal age; and Fertility Clinic Reports; 2011.
SES: Socioeconomic status; CSLD: Consortium of safe labor database; 15. Gray J, McCormick M, Richardson D, Ringer S: Normal birth weight
ACOG: American congress of obstetricians and gynecologists. intensive care unit survivors: outcome assessment. Pediatrics 1996,
97(6):832–833. 838.
Competing interests 16. Muraskas J, Parsi K: The cost of saving the tiniest lives: NICUs versus
The authors of this paper have nothing to disclose. prevention. Virtual Mentor, 10(10). 07/01/2011.
No financial or non-financial interests to declare. 17. Behrman RE, Stitch Butler A: Preterm birth: causes, consequences, and
prevention. Washington: National Academies Press; 2007:398.
Authors’ contributions
BEDJ, RL, DAP and MH contributed equally to this paper. MH worked with doi:10.1186/1471-2393-12-97
the Consortium of Safe Labor and carried out the collection of data at Cite this article as: de Jongh et al.: The differential effects of maternal
Christiana Care Hospital; he also contributed the knowledge of the maternal age, race/ethnicity and insurance on neonatal intensive care unit
risk factors. DAP was involved in the interpretation of data, as well as in the admission rates. BMC Pregnancy and Childbirth 2012 12:97.
critical revision of the manuscript prior to given it the final approval. RL and
BEDJ contributed equally to the conception and design of the study, analysis
and interpretation of the data; drafting the manuscript as well as the
revisions needed for the final version ready to be published. MH, DAP, RL
and BEDJ gave final approval of the version of the manuscript to be Submit your next manuscript to BioMed Central
published. All authors read and approved the final manuscript.
and take full advantage of:
Author details
1
Department of Neonatal-Perinatal Medicine, St. Christopher’s Hospital for • Convenient online submission
Children, Philadelphia, PA, USA. 2Department of Neonatology, Christiana Care • Thorough peer review
Health System, Newark, DE, USA. 3Department of Pediatrics, Thomas
• No space constraints or color figure charges
Jefferson University, Philadelphia, PA, USA. 4Department of Obstetrics and
Gynecology, Christiana Care Health System, Newark, DE, USA. 5Division of • Immediate publication on acceptance
Neonatal-Perinatal Medicine, St. Christopher’s Hospital for Children, • Inclusion in PubMed, CAS, Scopus and Google Scholar
Philadelphia, PA, USA.
• Research which is freely available for redistribution
Received: 18 December 2011 Accepted: 20 August 2012
Published: 17 September 2012 Submit your manuscript at
www.biomedcentral.com/submit