Rural-urban differences in obstetric care, 2002-2010, and implications for the future

A Qualitative Study of Systems-Level Factors That Affect Rural Obstetric Nurses' Work During Clinical Emergencies

BACKGROUND

Maternal morbidity and mortality is rising in the United States. Previous studies focus on patient attributes, and most of the national data are based on research performed at urban tertiary care centers. Although it is well understood that nurses affect patient outcomes, there is scant evidence to understand the nurse work system, and no studies have specifically studied rural nurses. The authors sought to understand the systems-level factors affecting rural obstetric nurses when their patients experience clinical deterioration.

METHODS

The research team used a qualitative descriptive approach, including a modified critical incident technique, in interviews with bedside nurses (n = 7) and physicians (n = 4) to understand what happens when patients experience clinical deterioration. Physicians were included to better understand the systems in which nurses work. Clinicians were interviewed at three rural hospitals in New England, with a mean births per year of 190.

FINDINGS

Six systems-level factors/themes were identified: (1) shortages of resources; (2) need for teamwork; (3) physicians' multiple conflicting and simultaneous responsibilities, such as seeing patients in the office while women labor on the hospital floor; (4) need for all team members to be at the top of their game; (5) process issues during high-acuity patient transfer, including difficulty finding available beds at tertiary care centers; and (6) insufficient policies that take low-resource contexts into account, such as requiring two registered nurses to remove emergency medications from the medication cabinet.

CONCLUSION

Rural nurses need policies and protocols that are written with their hospital context in mind. Hospitals may need outside support for content expertise, but policies should be co-created with clinicians with rural practice experience.

Rural-urban and racial differences in cesarean deliveries before and during the COVID-19 pandemic in South Carolina

PROBLEM

Unnecessary cesarean delivery increases the risk of complications for birthing people and infants.

BACKGROUND

Examining the intersectionality of rural and racial disparities in low-risk cesarean delivery is necessary to improve equity in quality obstetrics care.

AIM

To evaluate rural and racial/ethnic differences in Nulliparous, Term, Singleton, Vertex (NTSV) and primary cesarean delivery rates before and during the COVID-19 pandemic in South Carolina.

METHODS

This retrospective cohort study used birth certificates linked to all-payer hospital discharge data for South Carolina childbirths from 2018 to 2021. Multilevel logistic regressions examined differences in cesarean outcomes by rural/urban hospital location and race/ethnicity of birthing people during pre-pandemic (January 2018-February 2020) and peri-pandemic periods (March 2020-December 2021), adjusting for maternal, infant, and hospital characteristics among two low-risk pregnancy cohorts: 1) Nulliparous, Term, Singleton, Vertex (NTSV, n = 65,974) and 2) those without prior cesarean (primary, n = 167,928).

FINDINGS

Black vs. White disparities remained for NTSV cesarean in adjusted models (urban pre-pandemic aOR = 1.34, 95 %CI 1.23-1.46) but were not significantly different for primary cesarean, apart from rural settings peri-pandemic (aOR = 0.87, 95 %CI 0.79-0.96). Hispanic individuals had higher adjusted odds of NTSV cesarean only for rural settings pre-pandemic (aOR = 1.28, 95 %CI 1.05-1.56), but this disparity was not significant during the pandemic (aOR = 1.13, 95 %CI 0.93-1.37).

DISCUSSION AND CONCLUSION

Observed rural and racial/ethnic disparities in cesarean delivery outcomes were present before and during the COVID-19 pandemic. Strategies effective in reducing racial disparities in primary cesarean may be useful in also reducing Black vs. White NTSV cesarean disparities.

Catholic sole community hospitals are associated with decreased receipt of postpartum permanent contraception among Medicaid recipients

OBJECTIVES

To examine the association of Catholic hospitals with receipt of postpartum tubal ligation and long acting, reversible contraception among Medicaid recipients.

STUDY DESIGN

We conducted a retrospective cohort study of live births from January 1, 2016 to October 31, 2016 to female Medicaid beneficiaries in the United States between ages 21 and 44. Our main exposure was the presence of a Catholic-affiliated sole community hospital, and our primary outcome was highly effective postpartum contraception. We examined rates of postpartum permanent contraception, along with the use of a long acting, reversible form of contraception (LARC) at 3 and 60 days are postpartum. We compared counties that had only a Catholic-affiliated hospital with counties with only a non-Catholic hospital.

RESULTS

Our study population included 14,545 postpartum Medicaid beneficiaries. Study participants came from 88 counties across 10 United States states. Only 7.7% of women in counties with Catholic sole community hospitals received permanent contraception by 3 days postpartum, compared to 11.3% in counties with non-Catholic sole community hospitals (RD: -3.92%; 95% CI: -6.01%, -1.83%). This difference was not mitigated by receipt of outpatient procedures or long-acting, reversible contraception. Importantly, women residing in counties with Catholic sole community hospitals were much less likely to return postpartum for an outpatient visit between 8 and 60 days postpartum than women in counties with non-Catholic sole community hospitals (35.4% vs 45.4%, RD: -9.29%; 95% CI: -16.71%, -1.86%).

CONCLUSIONS

In counties where the only hospital was Catholic, Medicaid recipients giving birth were significantly less likely to receive permanent contraception and to return for postpartum care.

IMPLICATIONS

Catholic hospitals are increasing in the United States, which may restrict access to postpartum contraception, particularly in rural areas. We found that Medicaid recipients giving birth at a Catholic sole community hospital were less likely to receive permanent contraception and to return for care.

Disparities in Prenatal Immunization Rates in Rural and Urban US Areas by Indicators of Access to Care

PURPOSE

To evaluate disparities in urban-rural immunization rates among pregnant women by indicators of access to health care.

METHODS

We analyzed Phase 8 (2016-2018) Pregnant Risk Assessment Monitoring System data for 82,603 respondents who recently gave birth to a live infant. Uptake of influenza (33 states) or Tdap (19 states) vaccines was compared for rural versus urban areas of participating states. We compared the prevalence of immunization for rural versus urban areas by indicators of health care access using average marginal predictive values from multivariable regression models.

FINDINGS

Although nearly half (48.2%) of pregnant women in rural areas relied on Medicaid to fund prenatal care, rural-residing women were less likely to live in a state offering full coverage under Medicaid to pregnant women than urban-residing women (93.9% vs 98.0%, respectively). Among states with Medicaid programs not offering full access for pregnant women, influenza immunization coverage was 12% lower (aPR 0.88; 95% CI 0.82, 0.94) and Tdap immunization coverage was 20% lower (aPR 0.80; 95% CI 0.68, 0.95) for rural versus urban areas. Uninsured women in rural areas were less likely to receive influenza or Tdap vaccine compared to uninsured women in urban areas (aPR 0.65; 95% CI 0.50, 0.85 and aPR 0.73; 95% CI 0.57, 0.95, respectively).

CONCLUSIONS

Pregnant women residing in rural areas more commonly rely on Medicaid to financially support prenatal care but are less likely to have expanded or full access to Medicaid coverage, potentially contributing to disparities vaccine uptake during pregnancy and increased rates of vaccine-preventable disease.

Racial Disparities in Respectful Maternity Care During Pregnancy and Birth After Cesarean in Rural United States

OBJECTIVE

To describe the experiences of pregnancy and birth after cesarean of women who live in rural areas of the United States, including access to vaginal birth after cesarean (VBAC), type of maternity care provider, travel times, autonomy in decision making, and respectful maternity care.

DESIGN

Retrospective observational study.

SETTING

Online questionnaire of women who gave birth in the United States.

PARTICIPANTS

Women (N = 1,711) with histories of cesarean and subsequent births within 5 years of participating.

METHODS

We calculated descriptive and bivariate statistics by identified areas of residence and stratified measures of autonomy and respectful maternity care by self-identification as a member of a racialized group. We applied qualitative descriptive analysis to responses to an open-ended survey question.

RESULTS

A total of 299 (17.5%) participants identified their areas of residence as rural. Similar percentages of rural and metropolitan participants were able to plan VBAC (p = .88). More rural participants than metropolitan participants reported travel times of more than 60 minutes to give birth (p < .001), and fewer had obstetricians (p = .002) or doulas (p = .03). Rural participants from racialized groups experienced significantly less respectful maternity care than White, non-Hispanic rural participants and all metropolitan participants (p = .04). Qualitative data illustrating the main findings are included.

CONCLUSIONS

Our findings highlight challenges faced by rural residents accessing VBAC and help explain why rates of VBAC in rural areas remain low. We suggest a range of clinical and policy strategies to improve access to VBAC in rural areas and to improve the quality of maternity care for racialized women who live in rural areas.

Epidemiological characteristics and risk factors of obstetric infection after the Universal Two-Child Policy in North China: a 5-year retrospective study based on 268,311 cases

BACKGROUND

Obstetrical infection is one of the causes of maternal death and a difficult problem for many clinicians. Changes in the demographic and obstetric background of pregnant women following the Universal Two-Child Policy may have an impact on some fertility phenomena. And with the increase in the number of deliveries, the limited medical resources become more scarce. How will China's health system quickly adapt to the growing needs and expectations for maternal health and ensure the provision of qualified and accessible medical services? In addition, what social support measures should be provided to reduce preventable obstetric complications? Given the relatively low per capita share of medical resources in China, how should China deal with the impact of the Universal Two-Child Policy? Therefore, more studies based on the change of fertility policy are needed. We try to analyze the epidemiological characteristics and risk factors of obstetric infection before and after the Universal Two-Child Policy, with a view to providing reference for the prevention and control of obstetric infection in regions after the change of fertility policy, and also hope to make corresponding contributions to the solution of the above problems through relevant studies.

METHODS

The subjects of the survey were 268,311 pregnant women from Hebei Province Maternal Near Miss Surveillance System (HBMNMSS) of Hebei Women and Children's Health Center from January 1, 2013 to December 31, 2017. We analyzed the region, time and population distribution characteristics of obstetric infection, compared the epidemiological factors of obstetric infection before and after the Universal Two-Child Policy, and analyzed the relevant risk factors of obstetric infection.

RESULTS

The incidence of obstetric infection increased nearly twice after the Universal Two-Child Policy. The incidence of obstetric infection was highest in Chengde (1.9%), a city with a northward geographical distribution, Baoding (1.6%), Cangzhou (1.5%) followed; The higher the hospital grade, the higher the incidence; The incidence of obstetric infections in hospitals at all levels has increased; The age of onset before the Universal Two-Child Policy was (27.82 ± 5.047) years old, and the age after the Universal Two-Child Policy was (28.97 ± 4.880) years old; The incidence of obstetric infections is higher in winter. The rate of abortion-related infection (increased from 0.61 to 1.65%) and the rate of pregnant women with high school education (increased from 0.35 to 0.74%) increased significantly. The results of multivariate Logistic regression analysis after the Universal Two-Child Policy showed that anemia (OR = 1.249, 95%CI: 1.071-1.458), chronic hypertension (OR = 1.934, 95%CI: 1.375-2.722), mild preeclampsia (OR = 2.103, 95%CI: 1.323-3.344) and severe preeclampsia (OR = 2.228, 95%CI: 1.703-2.916) were independent risk factors for obstetric infection. Gestational age ≥ 37 weeks was a protective factor.

CONCLUSION

After the Universal Two-Child Policy, the prevention and control of obstetric infections should be strengthened, especially for abortion-related infections and elderly maternal with obstetric complications and complication in high-grade hospitals in winter. Educational background is also one of the factors that should be considered in the prevention of obstetric sensation. Prolonging gestational age is helpful to reduce the incidence of obstetric infection.

Inequities in Availability of Evidence-Based Birth Supports to Improve Perinatal Health for Socially Vulnerable Rural Residents

Rural residents in the United States (US) have disproportionately high rates of maternal and infant mortality. Rural residents who are Black, Indigenous, and People of Color (BIPOC) face multiple social risk factors and have some of the worst maternal and infant health outcomes in the U.S. The purpose of this study was to determine the rural availability of evidence-based supports and services that promote maternal and infant health. We developed and conducted a national survey of a sample of rural hospitals. We determined for each responding hospital the county-level scores on the 2018 CDC Social Vulnerability Index (SVI). The sample’s (n = 93) median SVI score [IQR] was 0.55 [0.25–0.88]; for majority-BIPOC counties (n = 29) the median SVI score was 0.93 [0.88–0.98] compared with 0.38 [0.19–0.64] for majority-White counties (n = 64). Among counties where responding hospitals were located, 86.2% located in majority-BIPOC counties ranked in the most socially vulnerable quartile of counties nationally (SVI ≥ 0.75), compared with 14.1% of majority-White counties. In analyses adjusted for geography and hospital size, certified lactation support (aOR 0.36, 95% CI 0.13–0.97), midwifery care (aOR 0.35, 95% CI 0.12–0.99), doula support (aOR 0.30, 95% CI 0.11–0.84), postpartum support groups (aOR 0.25, 95% CI 0.09–0.68), and childbirth education classes (aOR 0.08, 95% CI 0.01–0.69) were significantly less available in the most vulnerable counties compared with less vulnerable counties. Residents in the most socially vulnerable rural counties, many of whom are BIPOC and thus at higher risk for poor birth outcomes, are significantly less likely to have access to evidence-based supports for maternal and infant health.

Birth during off-hours: Impact of time of birth, staff´s seniority, and unit volume on maternal adverse outcomes-a population-based cross-sectional study of 87 065 deliveries

BACKGROUND

The aim of this study was to investigate whether time of birth, unit volume, and staff seniority impact the incidence of maternal complications in deliveries ≥34 + 0 gestational weeks.

METHODS

We conducted a population-based cross-sectional study of 87 065 deliveries occurring between 2004 and 2015 in ten public hospitals in Styria, Austria. A composite adverse maternal outcome measure of uterine atony, postpartum hysterectomy, postpartum bleeding, impaired wound healing, postpartum infections requiring antibiotic treatment, sepsis, or maternal death was used to compare outcomes by time of birth, unit volume, and staff seniority. Based on delivery data, generalized estimating equations (GEEs) were used to calculate the risk of maternal adverse outcomes.

RESULTS

Maternal adverse events occurred in 1.33% of deliveries. Incidence of maternal adverse events was highest for units with >1000 deliveries (adjusted OR 1.40; CI 95%: 1.16-1.69) and higher for perinatal centers (adjusted OR 1.35; CI 95%: 1.15-1.57) compared with reference units (500-1000 deliveries/year). Delivery during the daytime compared with the afternoon and nighttime did not affect the incidence of maternal complications (P = 0.765 and P = 0.136, respectively). Compared with resident-guided deliveries, the odds ratio for an adverse event was the same when a consultant attended the delivery (adjusted OR 1.13; CI 95%: 0.98-1.30) but lower in deliveries managed by midwives only (adjusted OR 0.21; CI 95%: 0.07-0.64).

CONCLUSION

Procedures performed during the night shift were not associated with increased complication rates. Delivery volume and high-volume centers were associated with the highest risk of maternal complications, and units with 500-1000 deliveries per year were the lowest. With increasing odds of pregnancy risks, these results change, and delivering in a high-volume center becomes at least as safe as delivering in a smaller unit.

Severe Maternal Morbidity and Mortality Risk at the Intersection of Rurality, Race and Ethnicity, and Medicaid

OBJECTIVE

We examined differences in rates of severe maternal morbidity and mortality (SMMM) among Medicaid-funded compared with privately insured hospital births through specific additive and intersectional risk by rural or urban geography, race and ethnicity, and clinical factors.

METHODS

We used maternal discharge records from childbirth hospitalizations in the Health care Cost and Utilization Project's National Inpatient Sample from 2007 to 2015. We calculated predicted probabilities using weighted multivariable logistic regressions to estimate adjusted rates of SMMM, examining differences in rates by payer, rurality, race and ethnicity, and clinical factors. To assess the presence and extent of additive risk by payer, with other risk factors, on rates of SMMM, we estimated the proportion of the combined effect that was due to the interaction.

RESULTS

In this analysis of 6,357,796 hospitalizations for childbirth, 2,932,234 were Medicaid funded and 3,425,562 were privately insured. Controlling for sociodemographic and clinical factors, the highest rate of SMMM (224.9 per 10,000 births) occurred among rural Indigenous Medicaid-funded births. Medicaid-funded births among Black rural and urban residents, and among Hispanic urban residents, also experienced elevated rates and significant additive interaction. Thirty-two percent (Bonferroni-adjusted 95% confidence interval, 19%-45%) of SMMM cases among patients with chronic heart disease were due to payer interaction, and 19% (Bonferroni-adjusted 95% confidence interval, 17%-22%) among those with cesarean birth were due to the interaction.

CONCLUSIONS

Heightened rates of SMMM among Medicaid-funded births indicate an opportunity for tailored state and federal policy responses to address the particular maternal health challenges faced by Medicaid beneficiaries, including Black, Indigenous, and rural residents.

Protocol versus practice: Deviations from guidelines in low-risk twin deliveries in the United States

BACKGROUND

Medical guidelines recommend vaginal delivery for low-risk twin pregnancies because cesareans increase the probability of maternal morbidity and mortality. Yet, vaginal delivery rates for twins are considerably lower than for comparable singletons. One explanation for this disparity argues that greater risk associated with twins warrants increased surgical intervention. An alternative explanation is that twin deliveries are more likely to deviate from protocols that advise vaginal birth.

METHODS

Using the 2017 Natality Detail File (N = 3,197,401), we measured alignment of vaginal birth and trial of labor (TOL) with the American College of Obstetricians and Gynecologists' guidelines for twin and singleton no-indicated-risk births. We calculated predicted probabilities for the population and by maternal race/ethnicity to assess whether low rates of vaginal births among twins are explained by associated risk factors, or by deviations from recommended delivery methods.

RESULTS

Overall, 31.2% of twins were born vaginally compared with 79.4% of singletons. Controlling for indicated risks, the predicted probability of vaginal birth for twins was 0.49 and 0.85 for singletons. The predicted probability of TOL for twins was 0.18 and 0.47 for singletons. Maternal race/ethnicity was only weakly associated with mode of delivery. These findings indicate that no-indicated-risk twin pregnancies, across maternal racial/ethnic categories, have lower probabilities of vaginal birth and TOL than would be expected with widespread adherence to current guidelines.

CONCLUSIONS

Given the life-threatening consequences that may result from unnecessary surgical procedures, our findings highlight the need for further research to illuminate medical and nonmedical mechanisms driving nonadherence to clinical guidelines for twin births.

Labor and Delivery Unit Closures in Rural Georgia from 2012 to 2016 and the Impact on Black Women: A Mixed-Methods Investigation

BACKGROUND

Obstetric provider coverage in rural Georgia has worsened, with nine rural labor and delivery units (LDUs) closing outside the Atlanta Metropolitan Statistical Area from 2012 to 2016. Georgia consistently has one of the highest maternal mortality rates in the nation and faces increased adverse health consequences from this decline in obstetric care.

OBJECTIVE

This study explores what factors may be associated with rural hospital LDU closures in Georgia from 2012 to 2016.

METHODS

This study describes differences between rural Georgia hospitals based on LDU closure status through a quantitative analysis of 2011 baseline regional, hospital, and patient data, and a qualitative analysis of newspaper articles addressing the closures.

RESULTS

LDUs that closed had higher proportions of Black female residents in their Primary Care Service Areas (PCSAs), of Black birthing patients, and of patients with Medicaid, self-pay or other government insurance; lower LDU birth volume; more women giving birth within their PCSA of residence; fewer obstetricians and obstetric provider equivalents per LDU; and fewer average annual births per obstetric provider. Qualitative results indicate financial distress primarily contributed to closures, but also suggest that low birth volume and obstetric provider shortage impacted closures.

CONCLUSIONS FOR PRACTICE

Rural LDU closure in Georgia has a disproportionate impact on Black and low-income women and may be prevented through funding maternity healthcare, financing LDUs, and addressing provider shortages.

Decline and Pronounced Regional Disparities in Medical Cocaine Usage in the United States

Background: Cocaine is a stimulant and Schedule II drug used as a local anesthetic and vasoconstrictor. Objective: This descriptive study characterized medical cocaine use in the United States. Methods: Retail drug distribution data from 2002 to 2017 were extracted for each state from the Drug Enforcement Administration, which reports on medical, research, and analytical chemistry use. The percentage of buyers (pharmacies, hospitals, and providers) was obtained. Use per state, corrected for population, was determined. Available cross-sectional data on cocaine use as reported by the Medicare and Medicaid programs for 2013-2017 and electronic medical records were examined. Results: Medical cocaine use decreased by -62.5% from 2002 to 2017. Hospitals accounted for 84.9% and practitioners for 9.9% of cocaine distribution in 2017. The number of pharmacies carrying cocaine dropped by -69.4%. The percentages of hospitals, practitioners, and pharmacies that carried cocaine in 2017 were 38.4%, 2.3%, and 0.3%, respectively. There was a 7-fold difference in 2002 (South Dakota, 76.1 mg/100 persons; Delaware, 10.1 mg/100 persons). Relative to the average state in 2017, those reporting the highest values (Montana, 20.1; North Dakota, 24.1 mg/100 persons) were significantly elevated. Cocaine use within the Medicare and Medicaid programs was negligible. Cocaine use within the Geisinger system was rare from 2002 to 2007 (<4 orders/100 000 patients per year) but increased to 48.7 in 2018. Conclusion and Relevance: If these pharmacoepidemiological patterns continue, licit cocaine may soon become a historical relic. The pharmacology and pharmacotherapeutics education of health care providers may need to be adjusted accordingly.

The Implementation of a Collaborative Pediatric Telesimulation Intervention in Rural Critical Access Hospitals

BACKGROUND

Over 5.8 million pediatric visits to rural emergency department (EDs) occur each year in the United States. Most rural EDs care for less than five pediatric patients per day and are not well prepared for pediatrics. Simulation has been associated with improvements in pediatric preparedness. The implementation of pediatric simulation in rural settings is challenging due to limited access to equipment and pediatric specialists. Telesimulation involves a remote facilitator interacting with onsite learners. This article aims to describe the implementation experiences and participant feedback of a 1-year remotely facilitated pediatric emergency telesimulation program in three critical-access hospitals.

METHODS

Three hospitals were recruited to participate with a nurse manager serving as the on-site lead. The managers worked with a study investigator to set up the simulation technology during an in-person pilot testing visit with the off-site facilitators. A curriculum consisting of eight pediatric telesimulations and debriefings was conducted over a 12-month period. Participant feedback was collected via a paper survey after each simulation. Implementation metrics were collected after each session including technical and logistic issues.

RESULTS

Of 147 participant feedback surveys 90% reported that pediatric simulations should be conducted on a regular basis and overall feedback was positive. Forty-seven of 48 simulations were completed on the first attempt with few major technologic issues. The most common issue encountered related to the simulator not working correctly locally and involved the facilitator running the session without the heart and lung sounds. All debriefings occurred without any issues.

CONCLUSIONS

This replicable telesimulation program can be used in the small, rural hospital setting, overcoming time and distance barriers and lending pediatric emergency medicine expertise to the education of critical-access hospital providers.

Fifty Years of Progress in Neonatal and Maternal Transport for Specialty Care

Specialty care for preterm and critically ill infants has evolved over many years. Neonatal intensive care nurseries were developed, and physicians and nurses learned how to provide intensive care for these infants. Neonatal and maternal (in utero) transport to tertiary centers became common in regionalized systems of care to facilitate the specialized care of high-risk neonates when childbirth occurred in settings without specialized personnel or equipment. Annually, nearly 70,000 neonatal transports occur in the United States. Although specialty care helps reduce rates of neonatal mortality, racial disparities and disparities between urban and rural areas exist. The purpose of this article is to review the progress achieved in neonatal and maternal transport over the past 50 years. The knowledge developed can be used to improve the care provided to women, their fetuses, and infants.

Maternal Opioids Usage and Cesarean Delivery Rates: A Retrospective Cross-Sectional Analysis

OBJECTIVE

The growing opioid crisis increasingly affects maternal care in the US and it is unknown if opioid use puts pregnant women at increased odds for cesarean delivery (CD). Understanding how opioids influence CD trends is important in improving maternal and neonatal outcomes. This study aims to understand the association of opioid use with CD in the context of the demographic, clinical, behavioral, and health system complexity.

METHODS

This retrospective cross-sectional analysis used representative data from the 2012-2014 National Inpatient Sample. Opioid use during pregnancy, CD, and other clinical variables were identified using ICD9 codes. Characteristics were assessed using bivariate and multivariate statistics. A logistic regression model was used to determine the association between opioid use and CD while controlling for confounders. Adjustments were made for rural/urban hospital location, regional median income, maternal age, race, and medical and pregnancy-related conditions.

RESULTS

The rate of CD in the overall sample was about 30%. Among opioids-users, the overall proportion of CD was significantly less (24.7%). The adjusted odds ratio for CD among opioids users was 0.74 (CI: 0.73-0.76, p < 0.001). This finding is unique to pregnant women who are covered by public insurance. In rural areas, the relationship between opioid use and CD was not significant.

CONCLUSION

Opioid use during pregnancy is associated with lower CD rates in urban settings. This evidence suggests that maternal care varies between rural and urban areas in relation to CD of pregnant opioid users compared to non-opioid users.

Prevalence and Predictors of Medical Complexity in a National Sample of VLBW Infants

BACKGROUND AND OBJECTIVES

Very low birth weight (VLBW) infants are at high risk for morbidities beyond the neonatal period and ongoing use of health care. Specific morbidities have been studied; however, a comprehensive landscape of medical complexity in VLBW infants has not been fully described. We sought to (1) describe the prevalence of complex chronic conditions (CCCs) and (2) determine the association of demographic, hospital, and clinical factors with CCCs and CCCs or death.

METHODS

This retrospective cross-sectional analysis of discharge data from the Kids' Inpatient Database (2009-2012) included infants with a birth weight <1500 g and complete demographics. Outcomes included having CCCs or having either CCCs or dying. Analyses were weighted; univariate and multiple logistic regression models were used to estimate unadjusted and adjusted odds ratios. A dominance analysis with Cox-Snell R ² determined the relative contribution of demographic, hospital, and clinical factors to the outcomes.

RESULTS

Among our weighted cohort of >78 000 VLBW infants, >50% had CCCs or died. After adjustments, the prevalence of CCCs or CCCs or death differed by sex, race and ethnicity, hospital location, US region, receipt of surgery, transfer status, and birth weight. Clinical factors accounted for the highest proportion of the model's ability to predict CCCs and CCCs or death at 93.3% and 96.3%, respectively, whereas demographic factors were 11.5% and 2.3% and hospital factors were 5.2% and 1.4%, respectively.

CONCLUSIONS

In this nationally representative analysis, medical complexity is high among VLBW infants. Varying contributions of demographic, hospital, and clinical factors in predicting medical complexity offer opportunities to investigate future interventions to improve care delivery and patient outcomes.

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.

Pregnancy health in POWERMOM participants living in rural versus urban zip codes

Background:

Pregnant women living in rural locations in the USA have higher rates of maternal and infant mortality compared to their urban counterparts. One factor contributing to this disparity may be lack of representation of rural women in traditional clinical research studies of pregnancy. Barriers to participation often include transportation to research facilities, which are typically located in urban centers, childcare, and inability to participate during nonwork hours.

Methods:

POWERMOM is a digital research app which allows participants to share both survey and sensor data during their pregnancy. Through non-targeted, national outreach a study population of 3612 participants (591 from rural zip codes and 3021 from urban zip codes) have been enrolled so far in the study, beginning on March 16, 2017, through September 20, 2019.

Results:

On average rural participants in our study were younger, had higher pre-pregnancy weights, were less racially diverse, and were more likely to plan a home birth compared to the urban participants. Both groups showed similar engagement in terms of week of pregnancy when they joined, percentage of surveys completed, and completion of the outcome survey after they delivered their baby. However, rural participants shared less HealthKit or sensor data compared to urban participants.

Discussion:

Our study demonstrated the feasibility and effectiveness of enrolling pregnant women living in rural zip codes using a digital research study embedded within a popular pregnancy app. Future efforts to conduct remote digital research studies could help fill representation and knowledge gaps related to pregnant women.

Ecological contributions to maternal-infant functioning: Differences between rural and urban family contexts

AIMS

This study considered urban-rural differences in maternal-infant interactions (sensitivity/responsiveness and synchrony/reciprocity), infant temperament, and parenting stress, for samples similar in socioeconomic and racial composition. Higher sensitivity/responsiveness and synchrony/reciprocity were hypothesized for urban dyads, with more challenging temperament profiles predicted for rural infants. Rural mothers were expected to report more parenting-role stress.

METHODS

Urban (n = 68; San Francisco Bay) and rural (n = 120; inland Pacific Northwest) mothers of infants provided ratings of temperament and parenting stress. Parental sensitivity/responsiveness and synchrony/reciprocity were coded from mother-infant play observations. Groups were compared via analyses of covariance.

RESULTS

Urban mothers demonstrated significantly more sensitivity/responsiveness and synchrony/reciprocity compared to their rural counterparts. Rural mothers rated their infants significantly higher in negative affectivity and distress in response to limitations.

CONCLUSION

Although socioeconomic status is traditionally implicated in rural and urban population differences, our results suggest other factors (e.g., isolation, access to resources) warrant further exploration. Rural ecology appears to present risk that should be examined more closely in maternal-infant interactions and child social-emotional development. The variability of risk within urban and rural classifications (e.g., suburban, inner-city) also requires consideration.

Availability of Common Pediatric Radiology Studies: Are Rural Patients at a Disadvantage?

BACKGROUND

Many families wish to have radiologic tests performed locally, especially when obtaining these tests in specialized pediatric centers would require long-distance travel with associated costs and inconveniences. The differential availability of specialized and common pediatric uroradiographic tests in rural and urban areas has not been described. We undertook this study to describe the availability of common radiographic tests ordered by pediatric urologists, and to identify disparities in the availability of radiographic tests between urban and rural locations.

MATERIALS AND METHODS

We surveyed all freestanding hospitals in Washington State on the availability of flat-plate abdominal radiograph (AXR), renal-bladder ultrasounds (RBUS), voiding cystourethrograms (VCUG), MAG-3 renal scans, and nuclear cystograms (NC) for children, as well as testing restrictions, availability of sedation for urology tests, and presence of onsite radiologists. Rural and urban hospitals were compared on these characteristics.

RESULTS

The survey was completed by 74 of 88 institutions (84.1%); 17 (23.0%) were rural (population <2500), 32 (43.2%) were in urban clusters (population 2500-50,000), and 25 (33.8%) were in urban areas (population >50,000). Seventy-three (98.6%) institutions offered AXR, 68 (91.9%) offered RBUS, 44 (59.5%) offered VCUG, 26 (35.1%) offered MAG-3, and 15 (20.3%) offered NC to children. All urban and most (16/17; 94.1%) rural institutions had shareable digital imaging capability. AXR (100% versus 96%, P = 0.88) and RBUS (70.6% versus 96%, P = 0.15) availability was similar in rural and urban settings, whereas VCUG (11.8% versus 72%, P = 0.001), MAG-3 (5.9% versus 60%, P = 0.006), and NC (0% versus 44%, P = 0.017) were more commonly available in urban settings. Fewer rural hospitals employed full-time, in-house radiologists (35.3% versus 96%, P < 0.0001) or offered sedation (6.3% versus 36%, P = 0.01) for testing, but an equal proportion had age restrictions on the tests offered (40% versus 17.6%, P = 0.50). Fellowship-trained pediatric radiologists (0% versus 16%, P = 0.39) and child life specialists (0% versus 20%, P = 0.28) worked exclusively in urban settings. Most hospitals offering specialized radiographic tests (VCUG: 90.9%; P < 0.0001 and MAG-3: 92.3%; P = 0.002) had onsite radiologists.

CONCLUSIONS

The geographically widespread availability of AXR and RBUS may represent an opportunity to offer families care closer to home, realizing cost and time savings. Anxious children and those requiring more specialized studies may benefit from referral to urban centers. The lack of rural radiologists may be an actionable barrier to availability of specialized radiology testing.

Maternal Opioid Use Disorder and Neonatal Abstinence Syndrome Among Rural US Residents, 2007-2014

PURPOSE

Opioid use disorder (OUD) during pregnancy is associated with poor maternal and infant outcomes, including neonatal abstinence syndrome (NAS), and both maternal OUD and NAS are increasing disproportionately among rural residents. This study describes the trajectory and characteristics associated with diagnosis of maternal OUD or NAS among rural residents who gave birth at different types of hospitals based on rural/urban location and teaching status.

METHODS

Hospital discharge data from the all-payer National Inpatient Sample were used to describe maternal OUD and infant NAS among rural residents from 2007-2014. Hospitals were categorized as rural, urban teaching, and urban nonteaching. We estimated incidence trends by hospital categories, followed by multivariable logistic regression analyses to identify correlates of OUD and NAS among rural residents, stratified by hospital category.

FINDINGS

Incidence of maternal OUD increased in all hospital categories, with higher rates (8.9/1,000 deliveries) among rural residents who gave birth at urban teaching hospitals compared with those who gave birth at rural hospitals (4.3/1,000 deliveries) or urban nonteaching hospitals (3.6/1,000 deliveries; P < .001). A similar pattern was observed for infant NAS. In multivariable models, the association between maternal OUD and infant NAS diagnoses and hospital category differed by rurality (micropolitan vs. noncore.) CONCLUSIONS: There has been a sustained increase in both maternal OUD and NAS diagnoses among rural residents. Measured sociodemographic and clinical correlates of maternal OUD and NAS differ by hospital category, indicating variability across hospital locations in patient populations and clinical needs for rural residents with these conditions.

Patient perspectives on loss of local obstetrical services in rural northern Minnesota

BACKGROUND

Obstetrical care has been declining in rural communities. We examined patient choices and perspectives from two rural northern Minnesota communities who lost their local obstetrical services in July 2015. Our purpose was to characterize obstetrical use patterns through the years leading to and following the closure and to explore the effects of the closure on these communities.

METHODS

Information introducing the project and providing access to the survey was mailed to women who received prenatal care in the communities of interest. Responses were analyzed quantitatively and qualitatively.

FINDINGS

Two hundred and one participants completed the survey with 356 deliveries reported from 1990 to 2016. Before the closure, there was a trend toward an increasing percentage of women electing regional delivery (P < .001); however, women were still 1.6 times more likely to choose local (62%) than regional (38%) delivery. Reasons for choosing delivery location changed over the decades. While birth experiences remained positive or extremely positive, anxiety about getting to the hospital rose 10-fold from 1990 to 2016 (5%-51%, P < .001). Women voiced substantial concern about the lack of local obstetrical services. Qualitative analysis revealed significant negative emotional reactions and concerns for the consequences of this loss for the viability of their rural communities.

CONCLUSIONS

Choices and opinions about obstetric care have significantly changed from 1990 to 2016 in rural Minnesota. Understanding these changes can help address shifting risks and costs to rural communities here and elsewhere in an effort to support and sustain healthy, viable rural communities.

The "July Effect" on Shoulder Arthroplasty: Are Complication Rates Higher at the Beginning of the Academic Year?

BACKGROUND

The "July effect" is a colloquialism asserting an increased rate of errors at the start of the academic year in teaching hospitals. This retrospective population-based study evaluated for the presence of the July effect in performing shoulder arthroplasty.

METHODS

Using the Nationwide Inpatient Sample for 2002 through 2011, a total of 178,590 patients undergoing shoulder arthroplasty at academic medical centers were identified and separated into 2 groups: 1) patients admitted during July and 2) patients admitted between August and June. Multivariable logistic regression was used to identify associations with inpatient mortality and adverse events, blood transfusion, prolonged length of stay (>75^th percentile) and non-routine discharge.

RESULTS

After adjusting for patient, procedure, and hospital characteristics in multivariable modeling, admission in July was not associated with increased risk for inpatient mortality (OR 1.6) aggregate morbidity, blood transfusion, prolonged length of stay, and non-routine discharge.

CONCLUSION

This nationwide database analysis shows that shoulder arthroplasty at academic medical centers is not associated with increased perioperative morbidity and resource utilization during the month of July.

Access To Obstetric Services In Rural Counties Still Declining, With 9 Percent Losing Services, 2004-14

Recent closures of rural obstetric units and entire hospitals have exacerbated concerns about access to care for more than twenty-eight million women of reproductive age living in rural America. Yet the extent of recent obstetric unit closures has not yet been measured. Using national data, we found that 9 percent of rural counties experienced the loss of all hospital obstetric services in the period 2004-14. In addition, another 45 percent of rural US counties had no hospital obstetric services at all during the study period. That left more than half of all rural US counties without hospital obstetric services. Counties with fewer obstetricians and family physicians per women of reproductive age and per capita, respectively; a higher percentage of non-Hispanic black women of reproductive age; and lower median household incomes and those in states with more restrictive Medicaid income eligibility thresholds for pregnant women had higher odds of lacking hospital obstetric services. The same types of counties were also more likely to experience the loss of obstetric services, which highlights the challenge of providing adequate geographic access to obstetric care in vulnerable and underserved rural communities.

Rural-urban differences in access to hospital obstetric and neonatal care: how far is the closest one?

OBJECTIVES

To quantify drive distances to hospital obstetric services and advanced neonatal care and to examine such disparities by residential rurality and insurance type.

STUDY DESIGN

Data for all-payer maternal childbirth hospitalizations in 2002 (N = 661,240) and 2013 (N = 634,807) from nine geographically dispersed states were linked with the American Hospital Association annual surveys to identify maternal residence zip codes and the addresses of hospitals with obstetric services or advanced neonatal care.

RESULTS

The uneven geographic distribution of hospital obstetric and advanced neonatal care increased between 2002 and 2013, varying by maternal residential rurality and insurance type. Women in rural non-core areas, with Medicaid or no insurance, and living in counties with lower income and educational attainment, had to travel farther to the nearest hospital with obstetric services or neonatal care than their counterparts.

CONCLUSIONS

Women in communities that are already socioeconomically disadvantaged face increasing and substantial travel distances to access perinatal care.

Rural community birth: Maternal and neonatal outcomes for planned community births among rural women in the United States, 2004-2009

BACKGROUND

Approximately 22% of women in the United States live in rural areas with limited access to obstetric care. Despite declines in hospital-based obstetric services in many rural communities, midwifery care at home and in free standing birth centers is available in many rural communities. This study examines maternal and neonatal outcomes among planned home and birth center births attended by midwives, comparing outcomes for rural and nonrural women.

METHODS

Using the Midwives Alliance of North America Statistics Project 2.0 dataset of 18 723 low-risk, planned home, and birth center births, rural women (n = 3737) were compared to nonrural women. Maternal outcomes included mode of delivery (cesarean and instrumental delivery), blood transfusions, severe events, perineal lacerations, or transfer to hospital and a composite (any of the above). The primary neonatal outcome was a composite of early neonatal intensive care unit or hospital admissions (longer than 1 day), and intrapartum or neonatal deaths. Analysis involved multivariable logistic regression, controlling for sociodemographics, antepartum, and intrapartum risk factors.

RESULTS

Rural women had different risk profiles relative to nonrural women and reduced risk of adverse maternal and neonatal outcomes in bivariable analyses. However, after adjusting for risk factors and confounders, there were no significant differences for a composite of maternal (adjusted odds ratio [aOR] 1.05 [95% confidence interval {CI} 0.93-1.19]) or neonatal (aOR 1.13 [95% CI 0.87-1.46]) outcomes between rural and nonrural pregnancies.

CONCLUSION

Among this sample of low-risk women who planned midwife-led community births, no increased risk was detected by rural vs nonrural status.

Obstetric Access and the Community Health Imperative for Rural Women

This study examined whether the closure of several inpatient obstetric units in rural New Hampshire affected birth outcomes. It is a secondary analysis of birth certificate data from 2005 through 2012 and includes 5881 births. There were no changes in perinatal outcomes. When examining outcomes based on distance travelled to place of birth, controlling for closures, women who traveled greater than 30 miles had fewer prenatal visits and lower birth weight and gestational age infants. Community services that provide prenatal care and/or home visiting are even more important when obstetric units are not available in the community.

Maternity care access, quality, and outcomes: A systems-level perspective on research, clinical, and policy needs

The quality of maternity care in the United States is variable, and access to care is tenuous for rural residents, low-income individuals, and people of color. Without accessible, timely, and high-quality care, certain clinical and sociodemographic characteristics of individuals may render them more vulnerable to poor birth outcomes. However, risk factors for poor birth outcomes do not occur in a vaccum; rather, health care financing, delivery, and organization as well as the policy environment shape the context in which patients seek and receive maternity care. This paper describes the relationship between access and quality in maternity care and offers a systems-level perspective on the innovations and strategies needed in research, clinical care, and policy to improve equity in maternal and infant health.

Association Between Maternal Comorbidities and Emergency Department Use Among a National Sample of Commercially Insured Pregnant Women

OBJECTIVES

Evidence suggests that, despite routine engagement with the health system, pregnant women commonly seek emergency care. The objectives of this study were to examine the association between maternal comorbidities and emergency department (ED) use among a national sample of commercially insured pregnant women.

METHODS

We conducted a retrospective cohort study using multipayer medical claims data maintained by the Health Care Cost Institute for women ages 18 to 44 years with a live singleton birth in 2011 (N = 157,786). The association between common maternal comorbidities (e.g., hypertension, gestational diabetes) and ED use during pregnancy was examined using multilevel models, while controlling for age, region, and residential zip code.

RESULTS

Twenty percent (n = 31,413) of pregnant women had one or more ED visit (mean ± SD = 1.52 ± 1.15). Among those who used the ED, 29% had two or more visits, and 11% had three or more visits. Emergency care seekers were significantly more likely to have one or more comorbid condition compared to those with no emergency care: 30% versus 21%, respectively (p < 0.001). Pregnant women with asthma had 2.5 times the likelihood of having had any ED visit (adjusted odds ratio [AOR] = 2.46, 95% confidence interval [CI] = 2.32-2.62). There was a significant increase in the probability (approximately 50%) of ED use among pregnant women with diabetes (AOR = 1.47, 95% CI = 1.33-1.63) or hypertension (AOR = 1.49, 95% CI = 1.43-1.55) or who were obese (AOR = 1.55, 95% CI = 1.47-1.64). Increased odds associated with gestational diabetes were more modest, resulting in a 13% increased odds of using the ED (AOR = 1.13, 95% CI = 1.07-1.18). Less than 0.6% of pregnant women (n = 177) received emergency care that resulted in a hospital admission. The admission rate was 0.4% (189 admissions/47,608 ED visits).

CONCLUSIONS

Among pregnant women, comorbidity burden was associated with more ED utilization. Efforts to reduce acute unscheduled care and improve care coordination during pregnancy should target interventions to patient comorbidity.

Rural Hospital Employment of Physicians and Use of Cesareans and Nonindicated Labor Induction

OBJECTIVE

Workforce issues constrain obstetric care services in rural US hospitals, and one strategy hospitals use is to employ physicians to provide obstetric care. However, little is known about the relationship between hospital employment of maternity care physicians and use of obstetric care procedures in rural hospitals. We examined the association between obstetric physician employment and use of cesareans and nonindicated labor induction.

STUDY DESIGN

We conducted a cross-sectional analysis of a telephone survey of all 306 rural hospitals providing obstetric care in 9 states from November 2013 to March 2014 and linked the survey data (N = 263, 86% response rate) to all-payer childbirth data on maternity care utilization from 2013 Statewide Inpatient Database (SID) hospital discharge data.

METHODS

Using logistic regression models, we assessed the proportion of a hospital's maternity care physicians employed by the hospital and estimated its association with utilization of low-risk and nonindicated cesareans, and nonindicated labor induction.

RESULTS

Rural hospitals that employed family physicians but not obstetricians had lower cesarean rates among low-risk pregnancies. Rural hospitals that employed only obstetricians did not show a relationship between employment and procedure utilization. Across hospitals with both obstetricians and family physicians, a 10% higher proportion of obstetricians employed was associated with 4.6% higher low-risk cesarean rates (4.6% [0.7%-8.4%]), while no significant relationship was found for the proportion of family physicians employed by a hospital.

CONCLUSIONS

In rural US hospitals, associations between physician employment and obstetric procedure use differed by physician mix and the types of physicians employed.

Determinants of disinfectant use among nurses in U.S. healthcare facilities

BACKGROUND

Disinfectant use among healthcare workers has been associated with respiratory disorders, especially asthma. We aimed to describe disinfectants used by U.S. nurses, and to investigate qualitative and quantitative differences according to workplace characteristics and region.

METHODS

Disinfectant use was assessed by questionnaire in 8,851 nurses. Hospital characteristics were obtained from the American Hospital Association database.

RESULTS

Working in a hospital was associated with higher disinfectant use (OR: 2.06 [95%CI: 1.89-2.24]), but lower spray use (0.74 [0.66-0.82]). Nurses working in smaller hospitals (<50 beds vs. ≥200 beds) were more likely to use disinfectants (1.69 [1.23-2.32]) and sprays (1.69 [1.20-2.38]). Spray use was lower in the West than in the Northeast (0.75 [0.58-0.97]).

CONCLUSION

Disinfectant use was more common among nurses working in smaller hospitals, possibly because they perform more diverse tasks. Variations in spray use by hospital size and region suggest additional targets for future efforts to prevent occupational asthma. Am. J. Ind. Med. 60:131-140, 2017. © 2016 Wiley Periodicals, Inc.

Uptake and Utilization of Practice Guidelines in Hospitals in the United States: the Case of Routine Episiotomy

BACKGROUND

The gap between publishing and implementing guidelines differs based on practice setting, including hospital geography and teaching status. On March 31, 2006, a Practice Bulletin published by the American College of Obstetricians and Gynecologists (ACOG) recommended against the routine use of episiotomy and urged clinicians to make judicious decisions to restrict the use of the procedure.

OBJECTIVE

This study investigated changes in trends of episiotomy use before and after the ACOG Practice Guideline was issued in 2006, focusing on differences by hospital geographic location (rural/urban) and teaching status.

METHODS

In a retrospective analysis of discharge data from the Nationwide Inpatient Sample (NIS)-a 20% sample of US hospitals-5,779,781 hospital-based births from 2002 to 2011 (weighted N = 28,067,939) were analyzed using multivariable logistic regression analysis to measure odds of episiotomy and trends in episiotomy use in vaginal deliveries.

RESULTS

The overall episiotomy rate decreased from 20.3% in 2002 to 9.4% in 2011. Across all settings, a comparatively larger decline in episiotomy rates preceded the issuance of the ACOG Practice Guideline (34.0% decline), rather than following it (23.9% decline). The episiotomy rate discrepancies between rural, urban teaching, and urban nonteaching hospitals remained steady prior to the guideline's release; however, differences between urban nonteaching and urban teaching hospitals narrowed between 2007 and 2011 after the guideline was issued.

CONCLUSION

Teaching status was a strong predictor of odds of episiotomy, with urban nonteaching hospitals having the highest rates of noncompliance with evidence-based practice. Issuance of clinical guidelines precipitated a narrowing of this discrepancy.

Association between Hospital Birth Volume and Maternal Morbidity among Low-Risk Pregnancies in Rural, Urban, and Teaching Hospitals in the United States

Objectives This study aims to examine the relationship between hospital birth volume and multiple maternal morbidities among low-risk pregnancies in rural hospitals, urban non-teaching hospitals, and urban teaching hospitals, using a representative sample of U.S. hospitals. Study Design Using the 2011 Nationwide Inpatient Sample from 607 hospitals, we identified 508,146 obstetric deliveries meeting low-risk criteria and compared outcomes across hospital volume categories. Outcomes include postpartum hemorrhage (PPH), chorioamnionitis, endometritis, blood transfusion, severe perineal laceration, and wound infection. Results Hospital birth volume was more consistently related to PPH than to other maternal outcomes. Lowest-volume rural (< 200 births) and non-teaching (< 650 births) hospitals had 80% higher odds (adjusted odds ratio [AOR] = 1.80; 95% CI = 1.56-2.08) and 39% higher odds (AOR = 1.39; 95% CI = 1.26-1.53) of PPH respectively, than those in corresponding high-volume hospitals. However, in urban teaching hospitals, delivering in a lower-volume hospital was associated with 14% lower odds of PPH (AOR = 0.86; 95% CI = 0.80-0.93). Deliveries in rural hospitals had 31% higher odds of PPH than urban teaching hospitals (AOR = 1.31; 95% CI = 1.13-1.53). Conclusions Low birth volume was a risk factor for PPH in both rural and urban non-teaching hospitals, but not in urban teaching hospitals, where higher volume was associated with greater odds of PPH.

Why Are Obstetric Units in Rural Hospitals Closing Their Doors?

OBJECTIVES

To understand hospital- and county-level factors for rural obstetric unit closures, using mixed methods.

DATA SOURCES

Hospital discharge data from Healthcare Cost and Utilization Project's Statewide Inpatient Databases, American Hospital Association Annual Survey, and Area Resource File for 2010, as well as 2013-2014 telephone interviews of all 306 rural hospitals in nine states with at least 10 births in 2010. Via interview, we ascertained obstetric unit status, reasons for closures, and postclosure community capacity for prenatal care.

STUDY DESIGN

Multivariate logistic regression and qualitative analysis were used to identify factors associated with unit closures between 2010 and 2014.

PRINCIPAL FINDINGS

Exactly 7.2 percent of rural hospitals in the study closed their obstetric units. These units were smaller in size, more likely to be privately owned, and located in communities with lower family income, fewer obstetricians, and fewer family physicians. Prenatal care was still available in 17 of 19 communities, but local women would need to travel an average of 29 additional miles to access intrapartum care.

CONCLUSIONS

Rural obstetric unit closures are more common in smaller hospitals and communities with a limited obstetric workforce. Concerns about continuity of rural maternity care arise for women with local prenatal care but distant intrapartum care.

A Comparison of the Charlson and Elixhauser Comorbidity Measures to Predict Inpatient Mortality After Proximal Humerus Fracture

OBJECTIVES

Proximal humerus fractures are very common in infirm elderly patients and are associated with appreciable inpatient mortality. We sought to compare the discriminative ability of the Charlson and Elixhauser comorbidity measures for predicting inpatient mortality after proximal humerus fractures.

METHODS

Data from the Nationwide Inpatient Sample (2002-2011) were obtained. We constructed 2 main multivariable logistic regression models, with inpatient mortality as the dependent variable and 1 of the 2 comorbidity scores, as well as age and sex, as independent variables. A base model that contained only age and sex was also evaluated. The predictive performance of the Charlson and Elixhauser comorbidity measures was assessed and compared using the area under the receiver operating characteristic curve (AUC) derived from these regression models.

RESULTS

Elixhauser comorbidity adjustment provided better discrimination of inpatient mortality [AUC = 0.840, 95% confidence interval (CI), 0.828-0.853] than the Charlson model (AUC = 0.786, 95% CI, 0.771-0.801) and the base model without comorbidity adjustment (AUC = 0.722, 95% CI, 0.705-0.740). In terms of relative improvement in predictive ability, the Elixhauser score performed 46% better than the Charlson score.

CONCLUSIONS

Given that inadequate comorbidity risk adjustment can unfairly penalize hospitals and surgeons that care for a disproportionate share of infirm and sick patients, wider adoption of the Elixhauser measure for mortality prediction after proximal humerus fracture-and perhaps other musculoskeletal injuries-merits to be considered.

Maternal risk factors and perinatal outcomes among pacific islander groups in Hawaii: a retrospective cohort study using statewide hospital data

Background

Studies suggest Pacific Islander women have disparate rates of preterm birth, primary cesarean delivery, preeclampsia, gestational diabetes, and low birthweight infants. However, data is limited. In order to improve the health of Pacific Islanders, it is essential to better understand differences in obstetric outcomes in this diverse population

Methods

This study compared perinatal outcomes between Pacific Islander (9,646) and White (n = 5,510) women who delivered a singleton liveborn in any Hawaii hospital from January 2010 to December 2011 using the Hawaii Health Information Corporation (HHIC) database. Pacific Islanders were disaggregated into the following groups: Native Hawaiian, Samoan, Micronesian, and Other Pacific Islanders. Perinatal outcomes (e.g. hypertensive diseases, birthweight, mode of delivery) were compared using multivariable logistic models controlling for relevant sociodemographic and health risk factors (e.g. age and payer type).

Results

Significant differences in perinatal outcomes between Pacific Islander and White women and newborns were noted. All Pacific Islander groups had an increased risk of hypertension. Outcome differences were also seen between Pacific Islanders groups. Native Hawaiians had the highest risk of low birthweight infants, Samoans had the highest risk of macrosomic infants and Micronesians had the highest risk of cesarean delivery.

Conclusions

Important differences in perinatal outcomes among Pacific Islanders exist. It is important to examine Pacific Islander populations separately in future research, public health interventions, and policy.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-015-0671-4) contains supplementary material, which is available to authorized users.

Breastfeeding Supportive Hospital Practices in the US Differ by County Urbanization Level

BACKGROUND

Breastfeeding rates are lower among infants living in rural areas of the United States, yet there are limited data on whether hospital breastfeeding support differs between rural and urban areas.

OBJECTIVE

This study aimed to describe whether maternity care practices supportive of breastfeeding vary by level of urbanization.

METHODS

We linked data from the 2007, 2009, and 2011 Maternity Practices in Infant Nutrition and Care (mPINC) surveys with Rural-Urban Continuum Codes to categorize hospital counties as metropolitan urbanized, nonmetropolitan urbanized, less urbanized, and thinly populated.

RESULTS

From 2007 to 2011, the average hospital mPINC score, a composite quality score ranging from 0 to 100, increased from 64 to 71 in metropolitan urbanized counties and from 54 to 65 in thinly populated areas. Scores were lowest in thinly populated counties in 2007 and 2009 and in less urbanized counties in 2011. Examination of 2011 mPINC scores by 7 domains of care revealed that hospitals in less urbanized counties had lower scores than those in metropolitan urbanized counties for feeding of breastfed infants, breastfeeding assistance, staff training, and structural and organizational aspects of care delivery; for 3 of these practices, scores were 10 or more points lower-breastfeeding assistance, structural and organizational aspects of care, and staff training. In contrast, hospitals in thinly populated areas had higher scores than in metropolitan areas for mother-infant contact and facility discharge care; differences were less than 10 points.

CONCLUSION

Interventions that specifically target rural hospitals may reduce the gap in access to hospital maternity care practices supportive of breastfeeding by population density.

Proximal humerus fracture with injury to the axillary artery: a population-based study

BACKGROUND

The available evidence regarding axillary artery injury as a result of proximal humerus fracture consists of individual case reports or small series. This study used nationally representative data to determine the prevalence and predictors of axillary artery injury secondary to proximal humerus fracture, and to characterise its influence on inpatient mortality, length of stay, cost and discharge disposition.

METHODS

An estimated 388,676 inpatients with a proximal humerus fracture were identified in the Nationwide Inpatient Sample between 2002 and 2011, 331 with concomitant axillary artery injury (8.5 per 10,000). Multivariable regression modelling was used to identify independent predictors of axillary artery injury and to assess its relationship with inpatient outcomes.

RESULTS

Factors associated with axillary artery injury were male sex (odds ratio (OR): 1.6, 95% confidence interval (CI): 1.2-2.0), atherosclerosis (OR: 3.7, 95% CI: 2.5-5.4), open fracture (OR: 2.9, 95% CI: 1.9-4.5) and the presence of concomitant injuries, including brachial plexus injury (OR: 109, 95% CI: 79-151), shoulder dislocation (OR: 3.4, 95% CI: 2.0-5.8), scapula fracture (OR: 3.4, 95% CI: 2.1-5.4) and rib fracture (OR: 2.5, 95% CI: 1.6-4.0). Axillary artery injury was associated with increased length of stay, costs and mortality, but it did not affect discharge disposition.

CONCLUSION

Our study provides important baseline information regarding the epidemiology of axillary artery injury secondary to proximal humerus fracture. Prompt identification of at-risk patients upon admission might lead to improved diagnosis and management of this vascular injury.

LEVEL OF EVIDENCE

Prognostic level II.

Who leaves the hospital against medical advice in the orthopaedic setting?

BACKGROUND

Patients who leave the hospital against medical advice are at risk for readmission and for a variety of complications and are likely to consume more healthcare resources. However, little is known about which factors, if any, may be associated with self-discharge (discharge against medical advice) among orthopaedic inpatients.

QUESTIONS/PURPOSES

We studied the frequency and factors associated with self-discharge in patients hospitalized for orthopaedic trauma and musculoskeletal infection.

METHODS

Using discharge records from the Nationwide Inpatient Sample (2002-2011), we identified approximately 7,067,432 patient hospitalizations for orthopaedic trauma and 5,488,686 for musculoskeletal infection. We calculated the proportions of admissions that ended in self-discharge for both trauma and infection patients; then, we examined patient demographics, diagnoses, and hospital factors. Multivariable logistic regression models were constructed to determine independent predictors of self-discharge.

RESULTS

Approximately one in 333 (0.3%) patients hospitalized for an isolated fracture and one in 47 (2.1%) patients with musculoskeletal infection left against medical advice. Patient characteristics associated with self-discharge included age < 75 years (trauma: odds ratio [OR] 2.7, 95% confidence interval [CI] 2.5-2.8, p < 0.001; infection: OR 3.9, 95% CI 3.8-4.1, p < 0.001), male sex (trauma: OR 1.7, 95% CI 1.7-1.8, p < 0.001; infection: OR 1.4, 95% CI 1.3-1.4, p < 0.001), black race/ethnicity (trauma: OR 1.5, 95% CI 1.4-1.6, p < 0.001; infection: OR 1.1, 95% CI 1.1-1.1, p < 0.001), low household income (trauma: OR 1.5, 95% CI 1.4-1.5, p < 0.001; infection: OR 1.4, 95% CI 1.4-1.4, p < 0.001), nonprivate insurance (Medicare [trauma: OR 1.7, 95% CI 1.6-1.8, p < 0.001; infection: OR 2.5, 95% CI 2.4-2.5, p < 0.001] and Medicaid [trauma: OR 2.6, 95% CI 2.5-2.7, p < 0.001; infection: OR 3.2, 95% CI 3.2-3.3, p < 0.001]), and no insurance coverage (trauma: OR 3.0, 95% CI 2.9-3.1, p < 0.001; infection: OR 3.5, 95% CI 3.4-3.5, p < 0.001), less medical comorbidity (trauma: OR 0.94 per one-unit increase in the number of comorbidities, 95% CI 0.93-0.95, p < 0.001; infection: OR 0.88, 95% CI 0.87-0.88, p < 0.001), alcohol (trauma: OR, 2.3, 95% 2.2-2.4, p < 0.001; infection: OR 1.5, 95% CI 1.5-1.5, p < 0.001), opioid (trauma: OR 2.9, 95% CI 2.7-3.1, p < 0.001; infection: OR 4.4, 95% CI 4.3-4.4, p < 0.001) and nonopioid drug abuse (trauma: OR, 2.0, 95% CI 1.9-2.1, p < 0.001; infection: OR 2.8, 95% CI 2.8-2.9, p < 0.001), psychosis (trauma: OR 1.3, 95%CI 1.2-1.3, p < 0.001; infection: OR 1.3, 95% CI 1.3, 1.4, p < 0.001), and AIDS/HIV infection (trauma: OR 1.5, 95% CI 1.2-1.8, p < 0.001; infection: OR 1.3, 95% CI 1.3-1.4, p < 0.001). Patients with upper extremity fractures (OR 1.9, 95% CI 1.8-1.9, p < 0.001) or fractures of the neck and trunk (OR 2.1, 95% CI 2.0-2.2, p < 0.001) were more likely to leave against medical advice than patients with lower extremity fractures. Among infection hospitalizations, patients with cellulitis had the highest odds of self-discharge compared with carbuncle/furuncle (OR 1.3, 95% CI 1.2-1.5, p < 0.001). Self-discharges were more likely to occur at hospitals of larger size (trauma: OR 1.2, 95% CI 1.1-1.2, p < 0.001; infection: nonsignificant), located in urban settings (trauma: OR 1.3, 95% CI 1.2-1.4, p < 0.001; infection: OR 1.6, 95% CI 1.5-1.6, p < 0.001), and in the Northeast (trauma: OR 1.7, 95% CI 1.6-1.8, p < 0.001; infection: OR 1.6, 95% CI 1.6-1.6, p < 0.001) than at small, rural hospitals in the South.

CONCLUSIONS

Our data can be used to promptly identify orthopaedic inpatients at higher risk of self-discharge on admission and target interventions to optimize treatment adherence. Strategies to enhance physician communication skills among patients with low health literacy, improve cultural sensitivity, and proactively address substance abuse issues early during hospital admission may aid in preventing discharge dilemmas and merit additional study.

LEVEL OF EVIDENCE

Level III, prognostic study. See the Instructions for Authors for complete description of levels of evidence.

The impact of hospital obstetric volume on maternal outcomes in term, non-low-birthweight pregnancies

OBJECTIVE

The impact of hospital obstetric volume specifically on maternal outcomes remains under studied. We examined the impact of hospital obstetric volume on maternal outcomes in low-risk women who delivered non-low-birthweight infants at term.

STUDY DESIGN

We conducted a retrospective cohort study of term singleton, non-low-birthweight live births from 2007-2008 in California. Deliveries were categorized by hospital obstetric volume categories and separately for nonrural hospitals (category 1: 50-1199 deliveries per year; category 2: 1200-2399; category 3: 2400-3599, and category 4: ≥3600) and rural hospitals (category R1: 50-599 births per year; category R2: 600-1699; category R3: ≥1700). Maternal outcomes were compared with the use of the chi-square test and multivariable logistic regression.

RESULTS

There were 736,643 births in 267 hospitals that met study criteria. After adjustment for confounders, there were higher rates of postpartum hemorrhage in the lowest-volume rural hospitals (category R1 adjusted odds ratio, 3.06; 95% confidence interval, 1.51-6.23). Rates of chorioamnionitis, endometritis, severe perineal lacerations, and wound infection did not differ between volume categories. Longer lengths of stay were observed after maternal complications (eg, chorioamnionitis) in the lowest-volume hospitals (16.9% prolonged length of stay in category 1 hospitals vs 10.5% in category 4 hospitals; adjusted odds ratio, 1.91; 95% confidence interval, 1.01-3.61).

CONCLUSION

After confounder adjustment, few maternal outcomes differed by hospital obstetric volume. However, elevated odds of postpartum hemorrhage in low-volume rural hospitals raises the possibility that maternal outcomes may differ by hospital volume and geography. Further research is needed on maternal outcomes in hospitals of different obstetric volumes.