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The experience of childbirth and its outcomes in the United States varies by race: Black and Hispanic infants face higher risks of neonatal morbidity and mortality even after accounting for clinical risk. Although perinatal disparities are rooted in a complex set of causes, there is increasing recognition that differential quality of care contributes to disparities.1–3 This has been most clearly demonstrated among preterm infants receiving care in the NICU. Minority infants and families are more likely to receive care in poor quality NICUs3,4 and within a NICU are more likely to receive worse care.1 In this issue of Pediatrics , Glazer et al5 found that in New York City, compared with white infants, Black and Hispanic term infants had increased risk of complications. The study confirms the grim reality of racial and ethnic disparities in infant outcomes in a low-risk population that accounts for 90% of all births. Disparities within individual hospitals were attenuated when adjusted for sociodemographic factors. However, the disparities measured across hospitals were significant. Prevalence of complications differed by race and ethnicity and by hospital. Infection rates demonstrated the widest variation: a sixfold difference between highest- and lowest-performing tertile of hospitals. Although other factors, such as data validity, case mix, and obstetric and neonatal practice variation may account for observed disparities between hospitals, and further investigation into underlying drivers of disparity is needed, this study adds to a growing body … Address correspondence to Ravi Dhurjati, PhD, Perinatal Health Systems, Department of Pediatrics, School of Medicine, Stanford University, 1265 Welch Rd, x1C31, Stanford CA 94035-5415. E-mail: dhurjati{at}stanford.edu

Reduction of cesarean section rates has been a difficult process that has not been easily accomplished by the institution of guidelines. It is more a process of changing physician behavior rather than of medical education. This article analyzed the role of intensive feedback of outcomes to bring about such changes. Two large private obstetric services in San Francisco, CA, were studied. Intensive outcomes feedback using a computerized information system, The Perinatal Data Center, regarding cesarean birth rates and a variety of obstetric outcomes was provided to the medical and nursing staff at one hospital. The other center served as a control. After the first observation period, the outcomes system was introduced to the second hospital. Finally, “open label” feedback, intradepartmental release of everyone's key statistics with names attached, was performed. Active management of labor was not practiced at either hospital. Results. Cesarean birth rates were stable in the baseline period from 1980 through 1988 at 24% to 25%. Introduction of the Perinatal Data Center outcomes system was associated with a reduction to 21% at the first hospital with no change in the control hospital. Subsequent introduction of the system 3 years later in the control hospital resulted in a decline from 25% to 20.5%. After merger of the two obstetric units and the institution of “open label” feedback, an additional decline to 18.5% was observed. Conclusion. Physician practice patterns and cesarean birth rates can be altered with the intensive use of comparative outcome data and strong physician leadership. Nonblinded, intradepartmental distribution of outcomes is an even more effective tool.