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Inequities Along the Early Intervention Care Cascade for Very Preterm Infants
Yarden S Fraiman1, Joanne F Keith1, Ashley L O'Donoghue2
1Department of Neonatology, Beth Israel Deaconess Medical Center, Division of Newborn Medicine, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
Insights
Racial and ethnic minority infants born very preterm experience significant inequities in accessing Early Intervention services, from referral to receiving an Individualized Family Service Plan (IFSP). Addressing these gaps requires targeted structural interventions to ensure equitable care for all at-risk infants.
Area of Science:
- Neonatal Development
- Public Health
- Health Equity
Background:
- Infants born before 32 weeks gestation face higher risks for developmental and functional issues.
- Early Intervention programs support at-risk infants, but disparities may affect access to services like Individualized Family Service Plans (IFSPs).
Purpose of the Study:
- To identify and quantify inequities within the Early Intervention Care Cascade for very preterm infants.
- To determine where disparities occur in the process from referral to IFSP attainment.
Main Methods:
- A longitudinal cohort study analyzed data from 7169 very preterm infants (born <32 weeks gestation) in Massachusetts (2012-2019).
- The Early Intervention Care Cascade steps (referral, evaluation, IFSP) were modeled using sequential logistic regression, adjusting for infant and family factors.
Main Results:
- Racial and ethnic minority infants were less likely to be referred, evaluated, and receive an IFSP compared to non-Hispanic White infants.
- Non-Hispanic Black infants showed lower odds for evaluation (aOR, 0.57) and IFSP receipt (aOR, 0.83) versus non-Hispanic White infants.
- Observed associations were reduced after adjusting for social variables, indicating a complex interplay of factors.
Conclusions:
- Significant inequities and attrition exist in the Early Intervention Care Cascade for very preterm infants.
- Targeted structural interventions are crucial at each stage to close the equity gap in developmental support services.
Importance:
Infants born at less than 32 weeks of gestation have an increased risk for adverse developmental and functional outcomes. The Early Intervention program provides developmental support to at-risk infants and has been shown to improve outcomes, but inequities may exist along the complex cascade from referral to receiving an Individualized Family Service Plan (IFSP).
Objectives:
To determine where inequities exist along the Early Intervention Care Cascade and to quantify their magnitude.
Design, Setting, And Participants:
This longitudinal cohort study used data from the Pregnancy to Early Life Longitudinal database, a Massachusetts population-based dataset linking live births and Early Intervention data. A total of 7169 very preterm infants (gestational age less than 32 weeks) born between January 1, 2012, through December 31, 2019, in Massachusetts were identified. These data were analyzed from January 2025 through July 2025.
Exposure:
Infant race and ethnicity, defined as the birthing individual's race.
Main Outcomes And Measures:
The primary outcomes were the steps along the Early Intervention Care Cascade, including referral to Early Intervention, evaluation, and a signed IFSP. The steps along the Early Intervention Care Cascade were modeled using sequential logistic regression models adjusted for infant and family covariables.
Results:
Of the 7169 infants, 567 identified as Asian/Pacific Islander, 1644 as Hispanic, 55 as Native American or Alaska Native, 1278 as non-Hispanic Black, and 3449 as Non-Hispanic White. There were 84%, 71.3%, and 64.5% who were referred, evaluated, and received an IFSP, respectively. Compared with non-Hispanic White infants, infants in racial and ethnic minority groups were less likely to be referred, evaluated, and receive an IFSP. Non-Hispanic Black infants had a numerically lower odds of referral (81.3%; adjusted odds ratio [aOR], 0.93; 95% CI, 0.77-1.44), evaluation (62.5%; aOR, 0.57; 95% CI, 0.46-0.70), and receiving an IFSP (55.0%; aOR, 0.83; 95% CI, 0.62-1.12) vs non-Hispanic White infants (84.6%, 75.4%, and 68.4%, respectively). Associations were attenuated when adjusting for infant and family social variables.
Conclusion And Relevance:
In this longitudinal cohort study of very preterm infants, there was notable inequity and attrition across the Early Intervention Care Cascade. Targeted structural interventions at each step can close the equity gap.
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