摘要：Objectives. We sought to determine the importance of socioeconomic factors, maternal comorbid conditions, antepartum and intrapartum complications of pregnancy, and fetal factors in mediating racial disparities in fetal deaths. Methods. We undertook a mediation analysis on a retrospective cohort study of hospital-based deliveries with a gestational age between 23 and 44 weeks in California, Missouri, and Pennsylvania from 1993 to 2005 (n = 7 104 674). Results. Among non-Hispanic Black women and Hispanic women, the fetal death rate was higher than among non-Hispanic White women (5.9 and 3.6 per 1000 deliveries, respectively, vs 2.6 per 1000 deliveries; P < .01). For Black women, fetal factors mediated the largest percentage (49.6%; 95% confidence interval [CI] = 42.7, 54.7) of the disparity in fetal deaths, whereas antepartum and intrapartum factors mediated some of the difference in fetal deaths for both Black and Asian women. Among Hispanic women, socioeconomic factors mediated 35.8% of the disparity in fetal deaths (95% CI = 25.8%, 46.2%). Conclusions. The factors that mediate racial/ethnic disparities in fetal death differ depending on the racial/ethnic group. Interventions targeting mediating factors specific to racial/ethnic groups, such as improved access to care, may help reduce US fetal death disparities. In the United States, there continue to be racial/ethnic disparities in perinatal outcomes such as fetal death. 1–4 Studies have identified factors that are associated with increased rates of fetal death overall, including advanced maternal age, 5–7 previous cesarean delivery, 8 inadequate prenatal care, 9 and some chronic medical conditions. 10–12 However, none of these studies examined whether higher fetal death rates seen in minority racial/ethnic groups are potentially mediated by factors that occur later in pregnancy. 13–15 Understanding these factors and whether these mediating factors differ between racial/ethnic groups will better focus potential interventions to reduce these disparities. We have identified factors that mediate racial/ethnic differences in fetal death rates between 23 and 44 weeks gestation. We grouped factors into 4 areas using the conceptual framework shown in Figure 1 . These sets of factors included socioeconomic factors; maternal preexisting comorbid conditions; antepartum and intrapartum factors, primarily complications of pregnancy; and fetal factors, specifically gestational age at delivery. Open in a separate window FIGURE 1— Hierarchical conceptual framework: racial/ethnic differences in fetal death, California, Missouri, Pennsylvania, 1993–2005. Note . SES = socioeconomic status. The residual disparity in fetal deaths, or fetal deaths unexplained by any of the included factors, is shown as the bottom pathway.
