Rural-Urban Differences In Severe Maternal Morbidity And Mortality In The US, 2007–15

Associations Between Rural or Urban Status, Health Outcomes and Behaviors, and COVID-19 Perceptions Among Meditation App Users: Longitudinal Survey Study

BACKGROUND

Rural and urban differences in health outcomes and behaviors have been well-documented, with significant rural health disparities frequently highlighted. Mobile health (mHealth) apps, such as meditation apps, are a novel method for improving health and behaviors. These apps may be a critical health promotion strategy during the COVID-19 pandemic and could potentially be used to address rural health disparities. However, limited research has assessed whether meditation app health outcomes are associated with rural and urban residence, and it is unclear whether disparities in health and behaviors between rural and urban populations would persist among meditation app users.

OBJECTIVE

We aimed to explore associations between rural or urban status, psychological outcomes, and physical activity among users of a mobile meditation app. We further aimed to explore associations between rural or urban status and perceived effects of COVID-19 on stress, mental health, and physical activity, and to explore changes in these outcomes in rural versus urban app users over time.

METHODS

This study was a secondary analysis of a national survey conducted among subscribers to the meditation app Calm. Eligible participants completed online baseline surveys from April to June 2020, and follow-up surveys from June to September 2020, assessing demographics, psychological outcomes, physical activity, and perceived effects of COVID-19 on stress, mental health, and physical activity.

RESULTS

Participants (N=8392) were mostly female (7041/8392, 83.9%), non-Hispanic (7855/8392, 93.6%), and White (7704/8392, 91.8%); had high socioeconomic status (income ≥US $100,000: 4389/8392, 52.3%; bachelor's degree or higher: 7251/8392, 86.4%); and resided in a metropolitan area core (rural-urban commuting area code 1: 7192/8392, 85.7%). Rural or urban status was not associated with baseline stress, depression, anxiety, pre-COVID-19 and current physical activity, or perceived effects of COVID-19 on stress, mental health, and physical activity. Repeated-measures models showed overall decreases in depression, anxiety, and perceived effects of COVID-19 on physical activity from baseline to follow-up, and no significant changes in stress or perceived effects of COVID-19 on stress and mental health over time. Models also showed no significant main effects of rural or urban status, COVID-19 statewide prevalence at baseline, or change in COVID-19 statewide prevalence.

CONCLUSIONS

We did not find associations between rural or urban status and psychological outcomes (ie, stress, depression, and anxiety), physical activity, or perceived effects of COVID-19 on stress, mental health, and physical activity. Rural or urban status does not appear to drive differences in outcomes among meditation app users, and the use of mHealth apps should continue to be explored as a health promotion strategy in both rural and urban populations. Furthermore, our results did not show negative cumulative effects of COVID-19 on psychological outcomes and physical activity among app users in our sample, the majority of whom were urban, White, female, and of high socioeconomic status. Further research is needed to investigate meditation app use as a health promotion strategy in rural and urban populations.

Race, Medicaid Coverage, and Equity in Maternal Morbidity

BACKGROUND

Severe maternal morbidity (SMM) affects 50,000 deliveries in the United States annually, with around 1.5 times the rates among Medicaid-covered relative to privately covered deliveries. Furthermore, large racial inequities exist in SMM for non-Hispanic Black women and Hispanic women with rates being 2.1 and 1.4 times higher than White women, respectively. This study aimed to compare the differences in SMM among women of different races/ethnicities and delivery insurance types. Quantifying the rates of SMM based on the intersection of race/ethnicity and insurance status can help to elucidate how multiple forms of oppression and racism may contribute to the substantial inequities in SMM among Black women.

METHODS

Using hospital discharge data from the Healthcare Cost and Utilization Project National Inpatient Sample (years 2016 and 2017), we conducted multivariate logistic models to evaluate equity in maternal outcomes among women with different primary payers, overall and stratified by race/ethnicity.

RESULTS

We found a rate of SMM equal to 138.3 per 10,000 deliveries. Differences in the rate of SMM among non-Hispanic Black, non-Hispanic Asian, and Hispanic women relative to White women were lower among Medicaid-covered deliveries relative to deliveries of all payer types. For example, among all payers, Black women had 2.17 (221.3 vs. 102.1 per 10,000) times the rate of SMM compared with White women; however, among Medicaid-covered deliveries, Black women had 1.84 (227.3 vs. 123.2) times the rate. Despite increased risk associated with Medicaid coverage (adjusted odds ratio, 1.12; 95% confidence interval, 1.07-1.16), the risk was no longer significant in the stratified regression including Black women (adjusted odds ratio, 1.06; 95% confidence interval, 0.98-1.15).

CONCLUSIONS

Our findings suggest that Black women with Medicaid do not have higher rates of SMM relative to Black women with private insurance. National and state policy efforts should continue to focus on addressing structural racism and other socioeconomic drivers of adverse maternal outcomes, including barriers to high-quality care among women with Medicaid coverage.

Maternity Units in Rural Hospitals in North Carolina: Successful Models for Staffing and Structure

OBJECTIVES

Almost 15% of all US births occur in rural hospitals, yet rural hospitals are closing at an alarming rate because of shortages of delivering clinicians, nurses, and anesthesia support. We describe maternity staffing patterns in successful rural hospitals across North Carolina.

METHODS

All of the hospitals in the state with ≤200 beds and active maternity units were surveyed. Hospitals were categorized into three sizes: critical access hospitals (CAHs) had ≤25 acute staffed hospital beds, small rural hospitals had ≤100 beds without being defined as CAHs, and intermediate rural hospitals had 101 to 200 beds. Qualitative data were collected at a selection of study hospitals during site visits. Eighteen hospitals were surveyed. Site visits were completed at 8 of the surveyed hospitals.

RESULTS

Nurses in CAHs were more likely to float to other units when Labor and Delivery did not have patients and nursing management was more likely to assist on Labor and Delivery when patient census was high. Anesthesia staffing patterns varied but certified nurse anesthetists were highly used. CAHs were almost twice as likely to accept patients choosing a trial of labor after cesarean section (CS) than larger hospitals, but CS rates were similar across all hospital types. Hospitals with only obstetricians as delivering providers had the highest CS rate (32%). The types of hospitals with the lowest CS rates were the hospitals with only family physicians (24%) or high proportions of certified nurse midwives (22%).

CONCLUSIONS

Innovative staffing models, including family physicians, nurse midwives, and nurse anesthetists, are critical for the survival of rural hospitals that provide vital maternity services in underserved areas.

Contraception and Reproductive Planning for Women With Cardiovascular Disease: JACC Focus Seminar 5/5

The majority of reproductive-age women with cardiovascular disease are sexually active. Early and accurate counseling by the cardiovascular team regarding disease-specific contraceptive safety and effectiveness is imperative to preventing unplanned pregnancies in this high-risk group of patients. This document, the final of a 5-part series, provides evidence-based recommendations regarding contraceptive options for women with, or at high risk for, cardiovascular disease as well as recommendations regarding pregnancy termination for women at excessive cardiovascular mortality risk due to pregnancy.

Team-Based Care of Women With Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum: JACC Focus Seminar 1/5

The specialty of cardio-obstetrics has emerged in response to the rising rates of maternal morbidity and mortality related to cardiovascular disease (CVD) during pregnancy. Women of childbearing age with or at risk for CVD should receive appropriate counseling regarding maternal and fetal risks of pregnancy, medical optimization, and contraception advice. A multidisciplinary cardio-obstetrics team should ensure appropriate monitoring during pregnancy, plan for labor and delivery, and ensure close follow-up during the postpartum period when CVD complications remain common. The hemodynamic changes throughout pregnancy and during labor and delivery should be considered with respect to the individual cardiac disease of the patient. The fourth trimester refers to the 12 weeks after delivery and is a key time to address contraception, mental health, cardiovascular risk factors, and identify any potential postpartum complications. Women with adverse pregnancy outcomes are at increased risk of long-term CVD and should receive appropriate education and longitudinal follow-up.

Meeting the Challenge of Perinatal Care in Rural Communities

The complexities of providing quality perinatal care within rural communities provide significant challenges to providers and policy makers. Provision of healthcare in rural communities is challenging on individual as well as community-based levels. A quality improvement lens is applied to consider key challenges that pertain to patients, providers, place, and policy. Potential solutions from a provider perspective include nurse-midwifery care and inclusion of advanced practice providers in a variety of specialties in addition to creating care models for registered nurses to practice at the top of their scope. To enhance access in the rural place, telehealth and coordination activities are recommended. Finally, policy approaches such as Perinatal Care Collaboratives, Area Health Education Centers, and enhanced financial resources to eliminate socioeconomic disparities will enhance perinatal care in rural communities.

USDA Special Supplemental Nutrition Program for Women, Infants and Children (WIC) Vendor Criteria: An Examination of US Administrative Agency Variations

The food retail environment has been directly linked to disparities in dietary behaviors and may in part explain racial and ethnic disparities in pregnancy-related deaths. The Special Supplemental Nutrition Program for Women, Infants and Children (WIC), administered by the United States Department of Agriculture, is associated with improved healthy food and beverage access due to its requirement for minimum stock of healthy foods and beverages in WIC-eligible stores. The selection and authorization criteria used to authorize WIC vendors varies widely from state to state with little known about the specific variations. This paper reviews and summarizes the differences across 16 of these criteria enacted by 89 WIC administrative agencies: the 50 states, the District of Columbia, five US Territories, and 33 Indian Tribal Organizations. Vendor selection and authorization criteria varied across WIC agencies without any consistent pattern. The wide variations in criteria and policies raise questions about the rational for inconsistency. Some of these variations, in combination, may result in reduced access to WIC-approved foods and beverages by WIC participants. For example, minimum square footage and/or number of cash register criteria may limit vendors to larger retail operations that are not typically located in high-risk, under-resourced communities where WIC vendors are most needed. Results highlight an opportunity to convene WIC stakeholders to review variations, their rationale, and implications thereof especially as this process could result in improved policies to ensure and improve healthy food and beverage access by WIC participants. More work remains to better understand the value of state WIC vendor authorization authority, particularly in states that have provided stronger monitoring requirements. This work might also examine if and how streamlining WIC vendor criteria (or at least certain components of them) across regional areas or across the country could provide an opportunity to advance interstate commerce and promote an equitable supply of food across the food system, while ensuring the protection for local, community-oriented WIC vendors.

Rural residency as a risk factor for severe maternal morbidity

PURPOSE

The goal of this study was to evaluate how rural/urban status and other risk factors alter women's odds of severe maternal morbidity (SMM) at delivery.

METHODS

This study used 48,608 Kentucky resident delivery hospitalization records from 2017. We used multiple logistic regression with interaction terms to evaluate the moderating effect of rural/urban residence with other risk factors. We reported adjusted odds ratios (aORs) and 95% confidence intervals (CIs) as measures for association with the outcome of SMM at delivery.

FINDINGS

The percentage of delivery hospitalizations with SMM was higher for women with rural (2.4%) versus metro (1.1%) or metro-adjacent (1.5%) residence (p < .001). Rural status moderated the effect of anemia on SMM. The aOR for SMM for women with anemia versus those without was 8.56 (CI: 4.89-14.97) in rural areas, two times higher than in metro areas (aOR 3.87; CI: 3.09-4.86). Kentucky Appalachian region (aOR 1.90; CI: 1.46-2.47), Black race (aOR 1.30; CI: 1.02-1.66), history of cesarean section (aOR 1.28; CI: 1.07-1.52), hypertension (aOR 10.55; CI: 5.67-19.62), and opioid use (aOR 1.72; CI: 1.19-2.47) were significantly associated with SMM.

CONCLUSION

Rural women in Kentucky are at an increased risk for SMM. Quality and safety programming should specifically address the needs of isolated subpopulations. Women living in rural areas are more likely to experience SMM given an anemia diagnosis. The underlying cause and clinical management of anemia may differ between rural and urban areas.

Neonatal brachial plexus palsy: associated birth injury outcomes, hospital length of stay and costs

OBJECTIVE

To compare the birth injury outcomes and hospital length of stay and costs among newborns delivered at 34-42 weeks with neonatal brachial plexus palsy (NBPP) versus those without.

STUDY DESIGN

We conducted a retrospective, cross-sectional study using data from the National Inpatient Sample to identify all newborns hospitalizations that occurred in the U.S. between 2016 and 2017. We included non-anomalous single liveborn delivered in-hospital at 34-42 weeks. The newborns with NBPP were identified by International Classification of Diseases, 10th Revision, Clinical Modification codes. Birth injury outcomes, and hospital length of stay and hospital costs were examined. A multivariable Poisson regression model with robust error variance was used to examine the association between NBPP and birth injury outcomes. A multivariable generalized linear regression model was used to examine the association between NBPP and hospital length of stay and hospital costs.

RESULTS

Of 7,019,722 non-anomalous single liveborn delivered at 34-42 weeks in the U.S. from 2016 to 2017, the rate of NBPP (n = 6695) was 0.95 per 1000 newborn hospitalizations. After multivariable regression adjustment, compared to newborns without NBPP, the risk of the composite birth injury outcome was 2.91 (95% CI 2.61-3.25) times higher in those with NBPP. Similar results of an increased risk among newborns with NBPP were observed in all individual birth injury outcomes. Compared to newborns without NBPP, after adjustment, the hospital length of stay was 1.48 (95% IC 1.38-1.59) times higher and the hospital costs were 2.21 (95% CI 1.97-2.48) times higher in those with NBPP.

CONCLUSIONS

Among newborns delivered at 34-42 weeks, the risk of associated birth injuries, hospital length of stay and costs, were significantly higher in newborns with NBPP than those without.

Assessment of Incidence and Factors Associated With Severe Maternal Morbidity After Delivery Discharge Among Women in the US

IMPORTANCE

Previous efforts to examine severe maternal morbidity (SMM) in the US have focused on delivery hospitalizations. Little is known about de novo SMM that occurs after delivery discharge.

OBJECTIVE

To investigate the incidence, timing, factors, and maternal characteristics associated with de novo SMM after delivery discharge among women in the US.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, data from the IBM MarketScan Multi-State Medicaid database and the IBM MarketScan Commercial Claims and Encounters database were used to construct a sample of women aged 15 to 44 years who delivered between January 1, 2010, and September 30, 2014. Severe maternal morbidity was reported by the timing of diagnosis, and the associated maternal characteristics were examined. Women in the Medicaid and commercial insurance sample were classified into 3 distinct outcome groups: (1) those without any SMM during the delivery hospitalization and the postdelivery period (reference group), (2) those who exhibited at least 1 factor associated with SMM during the delivery hospitalization, and (3) those who exhibited any factor associated with de novo SMM after delivery discharge (defined as SMM that was first diagnosed in the inpatient setting during the 6 weeks [or 42 days] after discharge from the delivery hospitalization, conditional on no factor associated with SMM being identified during delivery). Data were analyzed from February to July 2020.

EXPOSURES

Timing of SMM diagnosis.

MAIN OUTCOMES AND MEASURES

Women with SMM were identified using diagnosis and procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification for the 21 factors associated with SMM that were developed by the Centers for Disease Control and Prevention.

RESULTS

A total of 2 667 325 women in the US with delivery hospitalizations between 2010 and 2014 were identified; of those, 809 377 women (30.3%) had Medicaid insurance (30.3%; mean [SD] age, 25.6 [5.5] years; 51.1% White), and 1 857 948 women (69.7%; mean [SD] age, 30.6 [5.4] years; 36.4% from the southern region of the US) had commercial insurance. Among those with Medicaid insurance, 17 584 women (2.2%) experienced SMM during the delivery hospitalization, and 3265 women (0.4%) experienced de novo SMM after delivery discharge. Among those with commercial insurance, 32 079 women (1.7%) experienced SMM during the delivery hospitalization, and 5275 women (0.3%) experienced de novo SMM after hospital discharge. A total of 5275 SMM cases (14.1%) and 3265 SMM cases (15.7%) among women with commercial and Medicaid insurance, respectively, developed de novo within 6 weeks after hospital discharge; of those, 3993 cases (75.7%) in the commercial insurance cohort and 2399 cases (73.5%) in the Medicaid cohort were identified in the first 2 weeks after discharge. The most common factors associated with SMM varied based on the timing of diagnosis. In the Medicaid population, non-Hispanic Black women (adjusted odds ratio [aOR], 1.53; 95% CI, 1.48-1.58), Hispanic women (aOR, 1.46; 95% CI, 1.37-1.57), and women of other races or ethnicities (aOR, 1.40; 95% CI, 1.33-1.47) had higher rates of SMM during delivery hospitalization than non-Hispanic White women; however, only the disparity between Black and White women (aOR, 1.69; 95% CI, 1.57-1.81) persisted into the postdischarge period.

CONCLUSIONS AND RELEVANCE

In this study, 15.7% of SMM cases in the Medicaid cohort and 14.1% of SMM cases in the commercial insurance cohort first occurred after the delivery hospitalization, with notable disparities in factors and maternal characteristics associated with the development of SMM. These findings suggest a need to expand the focus of SMM assessment to the postdelivery discharge period.

U.S. Maternal Mortality Within a Global Context: Historical Trends, Current State, and Future Directions

In the United States, despite significant investment and the efforts of multiple maternal health stakeholders, maternal mortality (MM) has reemerged since 1987 and MM disparity has persisted since 1935. This article provides a review of the U.S. MM trajectory throughout its history up to its current state. From this longitudinal perspective, MM trends and themes are evaluated within a global context in an effort to understand the problems and contributing factors. This article describes domestic and worldwide strategies recommended by maternal health stakeholders to reduce MM.

Disparities in Cardiovascular Disease Outcomes Among Pregnant and Post-Partum Women

Background

The incidence of cardiovascular disease among pregnant women is rising in the United States. Data on racial disparities for the major cardiovascular events during pregnancy are limited.

Methods and Results

Pregnant and post‐partum women hospitalized from January 2007 to December 2017 were identified from the Nationwide Inpatient Sample. The outcomes of interest included: in‐hospital mortality, myocardial infarction, stroke, pulmonary embolism, and peripartum cardiomyopathy. Multivariate regression analysis was used to assess the independent association between race and in‐hospital outcomes. Among 46 700 637 pregnancy‐related hospitalizations, 21 663 575 (46.4%) were White, 6 302 089 (13.5%) were Black, and 8 914 065 (19.1%) were Hispanic. The trends of mortality and stroke declined significantly in Black women, but however, were mostly unchanged among White women. The incidence of mortality and cardiovascular morbidity was highest among Black women followed by White women, then Hispanic women. The majority of Blacks (62.3%) were insured by Medicaid while the majority of White patients had private insurance (61.9%). Most of Black women were below‐median income (71.2%) while over half of the White patients were above the median income (52.7%). Compared with White women, Black women had the highest mortality with adjusted odds ratio (aOR) of 1.45, 95% CI (1.21–1.73); myocardial infarction with aOR of 1.23, 95% CI (1.06–1.42); stroke with aOR of 1.57, 95% CI (1.41–1.74); pulmonary embolism with aOR of 1.42, 95% CI (1.30–1.56); and peripartum cardiomyopathy with aOR of 1.71, 95 % CI (1.66–1.76).

Conclusions

Significant racial disparities exist in major cardiovascular events among pregnant and post‐partum women. Further efforts are needed to minimize these differences.

Determinants of rural-urban differences in health care provider visits among women of reproductive age in the United States

BACKGROUND

Rural health disparities and access gaps may contribute to higher maternal and infant morbidity and mortality. Understanding and addressing access barriers for specialty women's health services is important in mitigating risks for adverse childbirth events. The objective of this study was to investigate rural-urban differences in health care access for women of reproductive age by examining differences in past-year provider visit rates by provider type, and quantifying the contributing factors to these findings.

METHODS AND FINDINGS

Using a nationally-representative sample of reproductive age women (n = 37,026) from the Medical Expenditure Panel Survey (2010-2015) linked to the Area Health Resource File, rural-urban differences in past-year office visit rates with health care providers were examined. Blinder-Oaxaca decomposition analysis quantified the portion of disparities explained by individual- and county-level sociodemographic and provider supply characteristics. Overall, there were no rural-urban differences in past-year visits with women's health providers collectively (65.0% vs 62.4%), however differences were observed by provider type. Rural women had lower past-year obstetrician-gynecologist (OB-GYN) visit rates than urban women (23.3% vs. 26.6%), and higher visit rates with family medicine physicians (24.3% vs. 20.9%) and nurse practitioners/physician assistants (NPs/PAs) (24.6% vs. 16.1%). Lower OB-GYN availability in rural versus urban counties (6.1 vs. 13.7 providers/100,000 population) explained most of the rural disadvantage in OB-GYN visit rates (83.8%), and much of the higher family physician (80.9%) and NP/PA (50.1%) visit rates. Other individual- and county-level characteristics had smaller effects on rural-urban differences.

CONCLUSION

Although there were no overall rural-urban differences in past-year visit rates, the lower OB-GYN availability in rural areas appears to affect the types of health care providers seen by women. Whether rural women are receiving adequate specialized women's health care services, while seeing a different cadre of providers, warrants further investigation and has particular relevance for women experiencing high-risk pregnancies and deliveries.

Initiatives to Reduce Maternal Mortality and Severe Maternal Morbidity in the United States : A Narrative Review

Maternal mortality and severe maternal morbidity are critical health issues in the United States, with unacceptably high rates and racial, ethnic, and geographic disparities. Various factors contribute to these adverse maternal health outcomes, ranging from patient-level to health system-level factors. Furthermore, a majority of pregnancy-related deaths are preventable. This review briefly describes the epidemiology of maternal mortality and severe maternal morbidity in the United States and discusses selected initiatives to reduce maternal mortality and severe maternal morbidity in the areas of data and surveillance; clinical workforce training and patient education; telehealth; comprehensive models and strategies; and clinical guidelines, protocols, and bundles. Related Health Resources and Services Administration initiatives are also described.

Regional Variations in Maternal Mortality and Health Workforce Availability in the United States

BACKGROUND

Skilled, high-quality health providers and birth attendants are important for reducing maternal mortality.

OBJECTIVE

To assess whether U.S. regional variations in maternal mortality rates relate to health workforce availability.

DESIGN

Comparison of regional variations in maternal mortality rates and women's health provider rates per population and identification of a relationship between these measures.

SETTING

U.S. health system.

PARTICIPANTS

Women of child-bearing age and women's health providers, as captured in federal data sources from the Centers for Disease Control and Prevention, Census Bureau, and Health Resources and Services Administration.

MEASUREMENTS

Regional-to-national rate ratios for maternal mortality and women's health provider availability, calculated per population for women of reproductive age. Provider availability was examined across occupations (obstetrician-gynecologists, internal medicine physicians, family medicine physicians, certified nurse-midwives), in service-based categories (birth-attending and primary care providers), and across the entire women's health workforce (all studied occupations).

RESULTS

Maternal deaths per population increased nationally from 2009 to 2017 and, in 2017, were significantly higher in the South and lower in the Northeast (P < 0.001) than nationally. The occupational composition and per-population availability patterns of the women's health workforce varied regionally in 2017. The South had the lowest availability in the nation for nearly every health occupation and category studied, and the Northeast had the highest. This exploratory analysis suggests that subnational levels of provider availability across a region may be associated with higher maternal mortality rates.

LIMITATIONS

No causal relationship was established. Nationally representative maternal mortality and health workforce data sources have well-known limitations. Low numbers of observations limit statistical analyses.

CONCLUSION

Regional variations in maternal mortality rates may relate to the availability of birth-attending and primary care providers.

PRIMARY FUNDING SOURCE

None.

Pre-Pregnancy Hypertension Among Women in Rural and Urban Areas of the United States

BACKGROUND

Rates of maternal mortality are increasing in the United States with significant rural-urban disparities. Pre-pregnancy hypertension is a well-established risk factor for adverse maternal and offspring outcomes.

OBJECTIVES

The purpose of this study was to describe trends in maternal pre-pregnancy hypertension among women in rural and urban areas in 2007 to 2018 in order to inform community-engaged prevention and policy strategies.

METHODS

We performed a nationwide, serial cross-sectional study using maternal data from all live births in women age 15 to 44 years between 2007 and 2018 (CDC Natality Database). Rates of pre-pregnancy hypertension were calculated per 1,000 live births overall and by urbanization status. Subgroup analysis in standard 5-year age categories was performed. We quantified average annual percentage change using Joinpoint Regression and rate ratios (95% confidence intervals [CIs]) to compare yearly rates between rural and urban areas.

RESULTS

Among 47,949,381 live births to women between 2007 and 2018, rates of pre-pregnancy hypertension per 1,000 live births increased among both rural (13.7 to 23.7) and urban women (10.5 to 20.0). Two significant inflection points were identified in 2010 and 2016, with highest annual percentage changes between 2016 and 2018 in rural and urban areas. Although absolute rates were lower in younger compared with older women in both rural and urban areas, all age groups experienced similar increases. The rate ratios of pre-pregnancy hypertension in rural compared with urban women ranged from 1.18 (95% CI: 1.04 to 1.35) for ages 15 to 19 years to 1.51 (95% CI: 1.39 to 1.64) for ages 40 to 44 years in 2018.

CONCLUSIONS

Maternal burden of pre-pregnancy hypertension has nearly doubled in the past decade and the rural-urban gap has persisted.

Associations Between Comorbidities and Severe Maternal Morbidity

OBJECTIVE

To evaluate the associations between the number of chronic conditions and maternal race and ethnicity (race) with the risk of severe maternal morbidity.

METHODS

Using the National Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, years 2016-2017, we examined risk of severe maternal morbidity among 1,480,925 delivery hospitalizations among women of different races and with different numbers of comorbid conditions using multivariable logistic regression.

RESULTS

The rate of severe maternal morbidity was 139.7 per 10,000 deliveries. Compared with women with no comorbidities (rate 48.5/10,000), there was increased risk of severe maternal morbidity among women with one comorbidity (rate 238.6; odds ratio [OR] 5.0, 95% CI 4.8-5.2), two comorbidities (rate 379.9; OR 8.1, 95% CI 7.8-8.5), or three or more comorbidities (rate 560; OR 12.1, 95% CI 11.5-12.7). In multivariable regressions, similar associations were noted for women with one (adjusted odds ratio [aOR] 4.4, 95% CI 4.2-4.6), two (aOR 6.6, 95% CI 6.3-6.9), or three or more comorbidities (aOR 9.1, 95% CI 8.7-9.6). Black women had higher rates of comorbid conditions than all other racial and ethnic groups, with 55% (95% CI 54-56%) of Black women having no comorbidities, compared with 67% (95% CI 67-68%) of White women, 68% (95% CI 67-69%) of Hispanic women, and 72% (95% CI 71-73%) of Asian women.

CONCLUSION

We found a dose-response relationship between number of comorbidities and risk of severe maternal morbidity, with the highest rates of severe maternal morbidity among women with three or more comorbidities. Focusing on the prevention and treatment of chronic conditions among women of childbearing age may have the potential to improve maternal outcomes across races and ethnicities.

Severe Maternal Morbidity, Race, and Rurality: Trends Using the National Inpatient Sample, 2012-2017

Background: Severe maternal morbidity is related to maternal mortality and an important measure of maternal health outcomes. Our objective was to evaluate differences in rates of severe maternal morbidity and mortality (SMM&M) by rurality and race, and examine these trends over time. Materials and Methods: It involves the retrospective cohort study of delivery hospitalizations from January 1, 2012 to December 31, 2017 from the National Inpatient Sample. We identified delivery hospitalizations using International Classification of Diseases, Ninth Revision, Clinical Modification and International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis and procedure codes and diagnosis-related groups. We used hierarchical regression models controlling for insurance status, income, age, comorbidities, and hospital characteristics to model odds of SMM&M. Results: The eligible cohort contained 4,494,089 delivery hospitalizations. Compared with women from small cities, women in the most urban and most rural areas had higher odds of SMM&M (urban adjusted odds ratio [aOR] 1.09, 95% confidence interval [1.04-1.14]; noncore rural aOR 1.24 [1.18-1.31]). Among White women, the highest odds of SMM&M were in noncore rural counties (aOR 1.20 [1.12-1.27]), while among Black women the highest odds were in urban (aOR 1.21 [1.11-1.31]) and micropolitan areas (aOR 1.36 [1.19-1.57]). Findings were similar for Hispanic, Native American, and other race women. Rates of SMM&M increased from 2012 to 2017, especially among urban patients. Conclusions: Women in the most urban and most rural counties experienced higher odds of SMM&M, and these relationships differed by race. These findings suggest particular areas for clinical leaders and policymakers to target to reduce geographic and racial disparities in maternal outcomes.

Local Capacity for Emergency Births in Rural Hospitals Without Obstetrics Services

BACKGROUND

Rural hospitals are closing obstetric units, and limited information is available about local emergency obstetric preparedness and capacity in rural communities where hospitals do not routinely provide this care.

OBJECTIVE

To describe emergency obstetric capacity at rural US hospitals that do not routinely offer childbirth services.

METHODS

Data from the 2018 American Hospital Association Annual Survey were used to identify a random sample of rural hospitals that did not offer obstetric services. A survey was developed based on World Health Organization criteria for obstetric emergencies. With data collected from 69 rural hospital emergency departments (48% response rate), we analyzed local capacity to support childbirth.

RESULTS

Most responding hospitals (65%) were located 30 or more miles away from a hospital with obstetric services. Some reported having emergency room births in the past year (28%), an unanticipated adverse birth outcome (32%), and/or a delay in urgent transport for a pregnant patient (22%). More than 90% of responding hospitals had capacity for blood transfusion, intravenous antibiotics or anticonvulsants, and basic neonatal resuscitation. However, less than one-fifth had capacity to perform surgery (16%), remove retained products of delivery (17%), or had a policy for emergency cesarean (18%). Almost all respondents (80%) reported the need for additional training or resources to handle emergency obstetric situations.

CONCLUSION

Many rural hospitals do not have basic capacity to provide emergency obstetric services. Programs and policies to improve this may focus on surgical care, clinician and staff training, transportation, and coordination with nearby hospitals that provide obstetric services.

Cardiovascular Contribution to Maternal Mortality

The United States is the only industrialized nation with an increasing maternal mortality. Many factors contribute to this worrisome US trend; among them, social and demographic factors, and congenital and acquired cardiac conditions. Cardiovascular disease is the leading cause of maternal mortality, and adverse outcomes related to cardiovascular disease disproportionately affect black and Hispanic mothers. This article addresses knowledge gaps related to the treatment of heart disease in pregnancy, initiatives to address these gaps, and guidelines and best practices surrounding the care of women affected by cardiovascular disease and their babies affected by cardiovascular disease.

A Century Later: Rural Public Health's Enduring Challenges and Opportunities

The US public health community has demonstrated increasing awareness of rural health disparities in the past several years. Although current interest is high, the topic is not new, and some of the earliest public health literature includes reports on infectious disease and sanitation in rural places. Continuing through the first third of the 20th century, dozens of articles documented rural disparities in infant and maternal mortality, sanitation and water safety, health care access, and among Black, Indigenous, and People of Color communities. Current rural research reveals similar challenges, and strategies suggested for addressing rural-urban health disparities 100 years ago resonate today. This article examines rural public health literature from a century ago and its connections to contemporary rural health disparities. We describe parallels between current and historical rural public health challenges and discuss how strategies proposed in the early 20th century may inform current policy and practice. As we explore the new frontier of rural public health, it is critical to consider enduring rural challenges and how to ensure that proposed solutions translate into actual health improvements. (Am J Public Health. 2020;110:1678-1686. https://doi.org/10.2105/AJPH.2020.305868).

Substance use disorders and risk of severe maternal morbidity in the United States

BACKGROUND

The contribution of substance use disorders to the burden of severe maternal morbidity in the United States is poorly understood. The objective was to estimate the independent association between substance use disorders during pregnancy and risk of severe maternal morbidity.

METHODS

Retrospective analysis of a weighted 53.4 million delivery hospitalizations from 2003 to 2016 among females aged>18 in the National Inpatient Sample. We constructed measures of substance use disorders using diagnostic codes for cannabis, opioids, and stimulants (amphetamines or cocaine) abuse or dependence during pregnancy. The outcome was the presence of any of the 21 CDC indicators of severe maternal morbidity. Using weighted multivariable logistic regression, we estimated the association between substance use disorders and adjusted risk of severe maternal morbidity. Because older age at delivery is predictive of severe maternal morbidity, we tested for effect modification between substance use and maternal age by age group (18-34 y vs >34 y).

RESULTS

Pregnant women with an opioid use disorder had an increased risk of severe maternal morbidity compared with women without an opioid use disorder (18-34 years: aOR: 1.51; 95 % CI: 1.41,1.61, >34 years: aOR: 1.17; 95 % CI: 1.00,1.38). Compared with their counterparts without stimulant use disorders, pregnant women with a simulant use disorder (amphetamines, cocaine) had an increased risk of severe maternal morbidity (18-34 years: aOR: 1.92; 95 % CI: 1.80,2.0, >34 years: aOR: 1.85; 95 % CI: 1.66,2.06). Cannabis use disorders were not associated with an increased risk of severe maternal morbidity.

CONCLUSION

Substance use disorders during pregnancy, particularly opioids, amphetamines, and cocaine use disorders, may contribute to severe maternal morbidity in the United States.

Racial and Ethnic Differences in Self-Rated Health Among Rural Residents

This study examines racial and ethnic differences in self-rated health among rural residents and whether these differences can be explained by socio-demographic characteristics. We used data from the 2011-2017 National Health Interview Survey to assess differences in self-rated health by race and ethnicity among rural residents (living in non-metropolitan counties; n = 46,883). We used logistic regression analyses to estimate the odds of reporting fair/poor health after adjusting for individual socio-demographic characteristics. Non-Hispanic Black and American Indian rural residents reported worse self-rated health than their non-Hispanic White counterparts (25.8% and 20.8% reporting fair/poor health, respectively, vs. 14.8%; p < 0.001). After adjusting for socio-demographic characteristics, disparities remained for non-Hispanic Black rural residents (Adjusted Odds Ratio = 1.55; 95% CI 1.36, 1.76). This study suggests more attention is required to address inequities among rural people and to develop policies to address structural racism and improve the health of all rural residents.

Characteristics of US Rural Hospitals by Obstetric Service Availability, 2017

Objectives. To describe characteristics of rural hospitals in the United States by whether they provide labor and delivery (obstetric) care for pregnant patients.Methods. We used the 2017 American Hospital Association Annual Survey to identify rural hospitals and describe their characteristics based on the lack or provision of obstetric services.Results. Among the 2019 rural hospitals in the United States, 51% (n = 1032) of rural hospitals did not provide obstetric care. These hospitals were more often located in rural noncore counties (counties with no town of more than 10 000 residents). Rural hospitals without obstetrics also had lower average daily censuses, were more likely to be government owned or for profit compared with nonprofit ownership, and were more likely to not have an emergency department compared with hospitals providing obstetric care (P for all comparisons < .001).Conclusions. Rural US hospitals that do not provide obstetric care are located in more sparsely populated rural locations and are smaller than hospitals providing obstetric care.Public Health Implications. Understanding the characteristics of rural hospitals by lack or provision of obstetric services is important to clinical and policy efforts to ensure safe maternity care for rural residents.

Changes in Hospital-Based Obstetric Services in Rural US Counties, 2014-2018

This study describes hospital-based obstetric service losses in rural US counties between 2014 and 2018 overall and by county population and urban adjacency.

Obstetrical Care in Rural Minnesota: Family Physician Perspectives on Factors Affecting the Ability to Provide Prenatal, Labor, and Delivery Care

PURPOSE

With decreasing access to rural obstetrical care, this study aimed to identify factors that contribute to the ability of Minnesota's rural communities to continue to offer obstetrical services locally. The study also sought to characterize attributes that differentiate rural communities that continue to offer obstetrical care from those that do not.

METHODS

Family medicine physicians practicing in communities of fewer than 20,000 people were interviewed through a phone survey that included multiple choice and open-ended questions. Quantitative and qualitative analyses were performed on data collected from the responses.

FINDINGS

Within the Minnesota communities represented (N = 25), prenatal care was provided broadly, regardless of whether labor and delivery services were available. For the communities providing local labor and delivery (N = 17), several factors seemed to be key to sustaining these services: having a sufficient cohort of delivering providers, having surgical backup, having accessible confident nurses and nurse anesthetists, sustaining a sufficient annual birth volume at the hospital, and having organizational and administrative support. In addition, supporting anesthesia and analgesic services, access to specialist consultation, having resources for managing and referring both newborn and maternal complications, and sustaining proper equipment were also requisite.

CONCLUSIONS

Rural Minnesota family medicine physicians practicing in communities providing local labor and delivery care emphasized several essential components for sustainable provision of these services. With awareness of these essential components, rural health care providers, administrators, and policy makers can focus resources and initiatives on efforts that are most likely to support a sustainable and coordinated rural labor and delivery program.

Severe Maternal Morbidity and Mortality Among Indigenous Women in the United States

Indigenous women are at increased risk for severe maternal morbidity and mortality, particularly those who live in rural areas.

OBJECTIVE:

To describe delivery-related severe maternal morbidity and mortality among indigenous women compared with non-Hispanic white (white) women, distinguishing rural and urban residents.

METHODS:

We used 2012–2015 maternal hospital discharge data from the National Inpatient Sample to conduct a pooled, cross-sectional analysis of indigenous and white patients who gave birth. We used weighted multivariable logistic regression and predictive population margins to measure health conditions and severe maternal morbidity and mortality (identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedure codes) among indigenous and white patients, to test for differences across both groups, and to test for differences between rural and urban residents within each racial category.

RESULTS:

We identified an estimated 7,561,729 (unweighted n=1,417,500) childbirth hospitalizations that were included in the analyses. Of those, an estimated 101,493 (unweighted n=19,080) were among indigenous women, and an estimated 7,460,236 (unweighted n=1,398,420) were among white women. The incidence of severe maternal morbidity and mortality was greater among indigenous women compared with white women (2.0% vs 1.1%, respectively; relative risk [RR] 1.8, 95% CI 1.6–2.0). Within each group, incidence was higher among rural compared with urban residents (2.3% for rural indigenous women vs 1.8% for urban indigenous women [RR 1.3, 95% CI 1.0–1.6]; 1.3% for rural white women vs 1.2% for urban white women [RR 1.1, 95% CI 1.1–1.2]).

CONCLUSION:

Severe maternal morbidity and mortality is elevated among indigenous women compared with white women. Incidence is highest among rural indigenous residents. Efforts to improve maternal health should focus on populations at greatest risk, including rural indigenous populations.

Post-Traumatic Stress Disorder and Severe Maternal Morbidity

Post-traumatic stress disorder (PTSD) accompanies miscarriage, intrauterine fetal demise, and preterm birth. Levels of PTSD may be higher for women who experience acute, life-threatening events during labor and delivery. Severe maternal morbidities or near misses for maternal death disproportionately impact African American, Hispanic, American Indian, and women in rural communities. Expanding research demonstrates association between severe maternal morbidity or near-miss events and PTSD. Multiple preceding conditions and intrapartum and postpartum events place women at higher risk for PTSD. Postpartum evaluation provides an opportunity for PTSD screening. Untreated perinatal PTSD impacts long-term maternal and child health and contributes to health disparities.

Overview of US Maternal Mortality Policy

The United States maternal mortality rate has been rising for many years putting the US out of step with peer countries. There are many complex reasons for the rise in maternal deaths and recent data has demonstrated that there is a disproportionate risk for women of color. This article provides an overview of current policy and policy issues aimed at improving the maternal mortality rate in the United States.