Rural-Urban Differences in the Utilization of Hospital-Based Care for Women of Reproductive Age

Inequities in Adequacy of Prenatal Care and Shifts in Rural/Urban Differences Early in the COVID-19 Pandemic

BACKGROUND

Adequate prenatal care is vital for positive maternal, fetal, and child health outcomes; however, differences in prenatal care utilization exist, particularly among rural populations. The COVID-19 pandemic accelerated the adoption of telehealth in prenatal care, but its impact on the adequacy of care remains unclear.

METHODS

Using Pregnancy Risk Assessment Monitoring System (PRAMS) data, this study examined prenatal care adequacy during the early-pandemic year (2020) and pre-pandemic years (2016-2019) and investigated rural-urban inequities. Logistic regression models assessed the association between the pandemic year and prenatal care adequacy, and considered barriers to virtual care as a covariate.

RESULTS

The sample consisted of 163,758 respondents in 2016-2019 and 42,314 respondents in 2020. Overall, the study participants were 12% less likely to receive adequate prenatal visits during the early-pandemic year (2020) compared with 2016-2019 (adjusted odds ratio [aOR] = 0.88; 95% confidence interval [CI] [0.86, 0.91]). Respondents in rural areas had lower odds of receiving adequate prenatal care compared with those in urban areas during both pre-pandemic years (aOR = 0.90; 95% CI [0.88, 0.93]) and the early-pandemic year (aOR = 0.94; 95% CI [0.88, 0.99]). However, after adjusting for barriers to virtual care, the difference between rural and urban areas in the early-pandemic year became nonsignificant (aOR = 0.93; 95% CI [0.78, 1.11]). Barriers to virtual care, including lack of phones, data, computers, internet access, and private space, were significantly associated with inadequate prenatal care.

CONCLUSION

During the early-pandemic year, PRAMS respondents experienced reduced adequacy of prenatal care. Although rural-urban inequities persisted, our results suggest that existing barriers to virtual care explained these inequities. Telehealth interventions that minimize these barriers could potentially enhance health care utilization among pregnant people.

Prepregnancy Emergency Department Use and Risks of Severe Maternal and Neonatal Morbidity in Canada

IMPORTANCE

Emergency department (ED) use during pregnancy may be associated with worse obstetrical outcomes, possibly because of differences in access to health care. It is not known whether ED use before pregnancy is associated with serious adverse maternal and perinatal outcomes.

OBJECTIVE

To study the association between prepregnancy ED use and adverse maternal and perinatal outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study was conducted in Ontario, Canada, and included all livebirths and stillbirths from April 2003 to January 2020.

EXPOSURES

Main exposure was any ED encounter within 90 days preceding the start of the index pregnancy.

MAIN OUTCOMES AND MEASURES

Primary outcome was a composite of severe maternal morbidity (SMM) from 20 weeks' gestation to 42 days' post partum. Secondary outcomes included severe neonatal morbidity (SNM) from 0 to 27 days, neonatal death, and stillbirth. Relative risks (RRs) were adjusted for maternal age, income, and rurality.

RESULTS

Of 2 130 245 births, there were 2 119 335 livebirths (99.5%) and 10 910 stillbirths (0.5%). The mean (SD) maternal age was 29.6 (5.4) years, 212 478 (9.9%) were rural dwelling, and 498 219 (23%) had 3 or more comorbidities. Among all births, 218 011 (9.7%) had a prepregnancy ED visit. The rate of SMM was higher among women with a prepregnancy ED visit than those without (22.3 vs 16.5 per 1000 births), with an RR of 1.34 (95% CI, 1.30-1.38) and an adjusted RR (aRR) of 1.37 (95% CI, 1.33-1.42). Compared with no prepregnancy ED visit, the aRR was higher in those with 1 (1.29; 95% CI, 1.24-1.34), 2 (1.51; 95% CI, 1.42-1.61), and 3 or more (1.74; 95% CI, 1.61-1.90) ED visits. Prepregnancy ED visits for a hematological (aRR, 13.60; 95% CI, 10.48-17.64), endocrine (aRR, 4.96; 95% CI, 3.72-6.62), and circulatory (aRR, 2.27; 95% CI, 1.68-3.07) conditions were associated with the highest aRRs for SMM. The rate of SNM was higher among newborns whose mother visited the ED within 90 days before pregnancy (68.2 vs 55.4 per 1000 births; aRR, 1.24; 95% CI, 1.22-1.26) as was the risk of neonatal death (aRR, 1.26; 95% CI, 1.16-1.37) and stillbirth (aRR, 1.18; 95% CI, 1.11-1.25).

CONCLUSIONS AND RELEVANCE

In this study, ED use was common before pregnancy. These findings suggest that ED use may not only reflect a woman's access to prepregnancy care but also higher future risk of severe maternal and perinatal morbidity, potentially offering a useful trigger for health system interventions to decrease adverse pregnancy outcomes.