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Bujimalla PV, Kenne KA, Steffen HA, Swartz SR, Wendt LH, Skibbe AM, Jackson JB, Rysavy MB. Effects of rurality and distance to care on perinatal outcomes over a 1-year period during the COVID-19 pandemic. J Rural Health 2024; 40:520-530. [PMID: 38151483 PMCID: PMC11186728 DOI: 10.1111/jrh.12820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/30/2023] [Accepted: 12/18/2023] [Indexed: 12/29/2023]
Abstract
PURPOSE Our aim was to investigate the roles of rurality and distance to care on adverse perinatal outcomes and COVID-19 seroprevalence at the time of delivery over a 1-year period. METHODS Data were collected from the electronic medical record on all pregnant patients who delivered at a single, large, Midwest academic medical center over 1 year. Rurality was classified using standard Rural-Urban Commuting Area codes. Geographic Information System tools were used to map outcomes. Data were analyzed with univariate and multivariate models, controlling for Body Mass Index (BMI), insurance status, and parity. FINDINGS A total of 2,497 patients delivered during the study period; 20% of patients were rural (n = 499), 18.6% were micropolitan (n = 466), and 61.4% were metropolitan (n = 1,532). 10.4% of patients (n = 259) were COVID-19 seropositive. Rural patients did not experience higher rates of any measured adverse outcomes than metropolitan patients; micropolitan patients had increased odds of preterm labor (OR = 1.41, P = .022) and pre-eclampsia (OR = 1.78, P<.001). Patients living 30+ miles away from the medical center had increased odds of preterm labor (OR = 1.94, P<.001), pre-eclampsia (OR = 1.73, P = .002), and infant admission to the neonatal intensive care unit (OR = 2.12, P<.001), as well as lower gestational age at delivery (β = -9.2 days, P<.001) and birth weight (β = -206 grams, P<.001). CONCLUSION Distance to care, rather than rurality, was the key predictor of multiple adverse perinatal outcomes in this cohort of deliveries over a 1-year period. Our study suggests that rurality should not be used as a standalone indicator of access to care without further knowledge of the specific barriers affecting a given population.
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Affiliation(s)
| | - Kimberly A. Kenne
- Department of Obstetrics and Gynecology, University of
Iowa, Iowa City, IA
| | | | - Samantha R. Swartz
- Department of Obstetrics and Gynecology, University of
Iowa, Iowa City, IA
| | - Linder H. Wendt
- Institute of Clinical and Translational Science,
University of Iowa, Iowa City, IA
| | - Adam M. Skibbe
- Department of Geographical and Sustainability Sciences,
University of Iowa, Iowa City, IA
| | | | - Mary B. Rysavy
- Department of Obstetrics and Gynecology, University of
Iowa, Iowa City, IA
- Department of Obstetrics, Gynecology and Reproductive
Sciences, University of Texas Health Science Center at Houston, Houston, TX
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2
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Wallace ME, Vilda D, Dyer L, Johnson I, Funke L. Health care use and health consequences of geographic lack of access to abortion and maternity care. Birth 2024; 51:363-372. [PMID: 37968858 PMCID: PMC11093883 DOI: 10.1111/birt.12792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 08/05/2023] [Accepted: 10/12/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Recent years have brought substantial declines in geographic access to abortion facilities and maternity care across the US. The purpose of this study was to identify the reproductive health consequences of living in a county without access to comprehensive reproductive health care services. METHODS We analyzed National Center for Health Statistics data on all live births occurring in the US in 2020. We used data on locations of abortion facilities and availability of maternity care in order to classify counties by level of access to comprehensive reproductive health care services and defined comprehensive reproductive health care deserts as counties that did not have an abortion facility in the county or in any neighboring county and did not have any maternity care practitioners. We fit modified Poisson regression models with generalized estimating equations to estimate the degree to which living in a comprehensive reproductive health care desert was associated with receipt of timely and adequate prenatal care and risk of preterm birth, controlling for individual-level and county-level characteristics. RESULTS In 2020, one third of counties in the US were comprehensive reproductive health care deserts (n = 1082), and 136,272 births occurred in these counties. In adjusted models, there was no difference in prenatal health care use (timeliness or adequacy of care) between persons in comprehensive reproductive health care deserts and those with full access to care, but the risk of preterm birth was significantly elevated (aRR =1.09, 95% CI = 1.06, 1.13). CONCLUSIONS Lack of access to comprehensive reproductive health care services may increase the incidence of preterm birth.
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Affiliation(s)
- Maeve E Wallace
- Department of Social, Mary Amelia Center for Women's Health Equity Research, Behavioral, and Population Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
| | - Dovile Vilda
- Department of Social, Mary Amelia Center for Women's Health Equity Research, Behavioral, and Population Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
| | - Lauren Dyer
- Department of Social, Mary Amelia Center for Women's Health Equity Research, Behavioral, and Population Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
| | - Iman Johnson
- Department of Social, Mary Amelia Center for Women's Health Equity Research, Behavioral, and Population Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
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3
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Fontenot J, Brigance C, Lucas R, Stoneburner A. Navigating geographical disparities: access to obstetric hospitals in maternity care deserts and across the United States. BMC Pregnancy Childbirth 2024; 24:350. [PMID: 38720255 PMCID: PMC11080172 DOI: 10.1186/s12884-024-06535-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/21/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Access to maternity care in the U.S. remains inequitable, impacting over two million women in maternity care "deserts." Living in these areas, exacerbated by hospital closures and workforce shortages, heightens the risks of pregnancy-related complications, particularly in rural regions. This study investigates travel distances and time to obstetric hospitals, emphasizing disparities faced by those in maternity care deserts and rural areas, while also exploring variances across races and ethnicities. METHODS The research adopted a retrospective secondary data analysis, utilizing the American Hospital Association and Centers for Medicaid and Medicare Provider of Services Files to classify obstetric hospitals. The study population included census tract estimates of birthing individuals sourced from the U.S. Census Bureau's 2017-2021 American Community Survey. Using ArcGIS Pro Network Analyst, drive time and distance calculations to the nearest obstetric hospital were conducted. Furthermore, Hot Spot Analysis was employed to identify areas displaying significant spatial clusters of high and low travel distances. RESULTS The mean travel distance and time to the nearest obstetric facility was 8.3 miles and 14.1 minutes. The mean travel distance for maternity care deserts and rural counties was 28.1 and 17.3 miles, respectively. While birthing people living in rural maternity care deserts had the highest average travel distance overall (33.4 miles), those living in urban maternity care deserts also experienced inequities in travel distance (25.0 miles). States with hotspots indicating significantly higher travel distances included: Montana, North Dakota, South Dakota, and Nebraska. Census tracts where the predominant race is American Indian/Alaska Native (AIAN) had the highest travel distance and time compared to those of all other predominant races/ethnicities. CONCLUSIONS Our study revealed significant disparities in obstetric hospital access, especially affecting birthing individuals in maternity care deserts, rural counties, and communities predominantly composed of AIAN individuals, resulting in extended travel distances and times. To rectify these inequities, sustained investment in the obstetric workforce and implementation of innovative programs are imperative, specifically targeting improved access in maternity care deserts as a priority area within healthcare policy and practice.
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Affiliation(s)
- Jazmin Fontenot
- Perinatal Data Center, March of Dimes, 1550 Crystal Drive Suite 1300, Arlington, VA, USA.
| | - Christina Brigance
- Perinatal Data Center, March of Dimes, 1550 Crystal Drive Suite 1300, Arlington, VA, USA
| | - Ripley Lucas
- Perinatal Data Center, March of Dimes, 1550 Crystal Drive Suite 1300, Arlington, VA, USA
| | - Ashley Stoneburner
- Perinatal Data Center, March of Dimes, 1550 Crystal Drive Suite 1300, Arlington, VA, USA
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4
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Durrance C, Guldi M, Schulkind L. The effect of rural hospital closures on maternal and infant health. Health Serv Res 2024; 59:e14248. [PMID: 37840011 PMCID: PMC10915477 DOI: 10.1111/1475-6773.14248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Abstract
OBJECTIVE To evaluate the effect of rural hospital closures on infant and maternal health outcomes. DATA SOURCES AND STUDY SETTING We used restricted National Vital Statistics System birth and linked birth and infant death data, merged with county-level hospital closures from the Sheps Center for the period 2005-2019. STUDY DESIGN We used difference-in-difference and event study methods, employing new estimators that account for staggered treatment timing. Our key outcome variables were prenatal care initiation; birth outcomes (<2500 g; <1500 g; <37 weeks; <28 weeks; 5-min Apgar); delivery outcomes (cesarean, induction, hospital birth); and infant death (<1 year of birth; <=30 days of birth; <=7 days of birth; <= 1 day after birth). DATA COLLECTION/EXTRACTION METHODS The analysis covered all births in the United States in rural counties (by rurality: all, most, moderately rural). PRINCIPAL FINDINGS We found evidence that fewer individuals delivered in their county of residence after a hospital closure, and this was most pronounced for residents of the most rural counties (29%-52% decline (p < 0.01) in the likelihood of delivering in their residence county). We found that hospital closures worsen prenatal, infant, and delivery outcomes for residents of moderately rural counties but improve those outcomes for those in the most rural counties. In moderately rural counties, low birth weight births increased by 10.4% (p < 0.01). We found suggestive evidence of decreased infant deaths in the most rural counties. This pattern of findings is consistent with closures leading residents of the most rural counties to seek care in a different county and residents of moderately rural counties to seek care at a different hospital in the same county. CONCLUSIONS Loss of hospital care has meaningful effects on the rural populations; investigating rural counties in aggregate may miss nuanced differences in the effects on the margin of rurality.
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Affiliation(s)
- Christine Durrance
- La Follette School of Public AffairsUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Melanie Guldi
- Department of EconomicsUniversity of Central FloridaOrlandoFloridaUSA
| | - Lisa Schulkind
- Department of Economics, Belk College of BusinessUniversity of North Carolina at CharlotteCharlotteNorth CarolinaUSA
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Hansen A, Schoenberg N, Oser C. Insights from obstetric providers and emergency medical technicians on determinants of maternal morbidity and mortality among underserved, rural patients in the United States. SSM. QUALITATIVE RESEARCH IN HEALTH 2023; 4:100320. [PMID: 38239392 PMCID: PMC10795728 DOI: 10.1016/j.ssmqr.2023.100320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Affiliation(s)
- Anna Hansen
- University of Kentucky, College of Medicine, USA
| | | | - Carrie Oser
- University of Kentucky, College of Medicine, USA
- University of Kentucky, College of Arts and Sciences, USA
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6
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Chaturvedi R, Lui B, Tangel VE, Abramovitz SE, Pryor KO, Lim KG, White RS. United States rural residence is associated with increased acute maternal end-organ injury or mortality after birth: a retrospective multi-state analysis, 2007-2018. Int J Obstet Anesth 2023; 56:103916. [PMID: 37625988 DOI: 10.1016/j.ijoa.2023.103916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 06/22/2023] [Accepted: 07/26/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Geographic-based healthcare determinants and choice of anesthesia have been shown to be associated with maternal morbidity and mortality. We explored whether differences in maternal outcomes based on maternal residence, and anesthesia type for cesarean and vaginal birth, exist. METHODS This study was a retrospective multi-state analysis; patient residence was the predictor variable of interest and a composite binary measure of maternal end-organ injury or inpatient mortality was the primary outcome. Our secondary outcomes included a binary measure of anesthesia type for cesarean birth (general vs. neuraxial [NA]) and NA analgesia for vaginal birth (no NA vs. NA). Our predictor variable of interest was patient residency (reference category central metropolitan areas of >1 million population), fringe large metropolitan county, medium metropolitan, small metropolitan, micropolitan, and non-metropolitan or micropolitan county. RESULTS Women residing in micropolitan (OR 1.17; 95% CI 1.09 to 1.27) and non-metropolitan or micropolitan counties (OR 1.14; 95% CI 1.04 to 1.24) had the highest adjusted increased odds of adverse maternal outcomes. Those residing in suburban, medium, and small metropolitan areas underwent general anesthesia less often during cesarean births than those residing in urban areas. Patients residing in micropolitan rural (OR 2.07; 95% CI 2.02 to 2.12) and non-metropolitan or micropolitan (2.25; 95% CI 2.16 to 2.34) counties underwent vaginal births without NA analgesia more than twice as often as those residing in urban areas. CONCLUSIONS Rural-urban disparities in maternal end-organ damage and mortality exist and anesthesia choice may play an important role in these disparate outcomes.
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Affiliation(s)
- R Chaturvedi
- New York Presbyterian Weill Cornell Medical Center, New York, NY, USA
| | - B Lui
- Weill Cornell Medical College, Weill Cornell Medicine, New York, NY, USA
| | - V E Tangel
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - S E Abramovitz
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - K O Pryor
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - K G Lim
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - R S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA.
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7
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Deng S, Bennett K. On the geographic access to healthcare, beyond proximity. GEOSPATIAL HEALTH 2023; 18. [PMID: 37768173 DOI: 10.4081/gh.2023.1199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 07/10/2023] [Indexed: 09/29/2023]
Abstract
This study examined the incongruence of travel distance between the nearest provider and the provider that pregnant woman actually chose to visit. Using a dataset of South Carolina claims including rural and urban areas for the period 2014-2018 based on live births of 27,290 pregnant women, we compared the travel distance and travel time for two providers of health: the nearest facility and the main one for the area in question. The number of the former type was counted for every case. The mean travel distance/time to the nearest provider was 3.2 miles (5.2 km) and 5.0 minutes, while that to the main (predominant) provider was 23.0 miles (37.0 km) and 31.7 minutes. Only 21.6% of pregnant women chose one of the closest facilities as their provider. The mean travel distance and time to the nearest provider for women in rural areas were more than twice that for urban women but only 1.2 times for the main provider. Rural women had one third fewer providers situated closer than the main in comparison to number available for urban women. Thus, we conclude that proximity is not the only factor associated with access to healthcare. While evaluating geographic access, the number of available health providers within the mean travel distance or time would be a better indicator of proximate access.
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Affiliation(s)
- Songyuan Deng
- South Carolina Center for Rural and Primary Healthcare, University of South Carolina, Columbia, South Carolina.
| | - Kevin Bennett
- South Carolina Center for Rural and Primary Healthcare, University of South Carolina, Columbia, South Carolina.
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8
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Radke SM, Smeins L, Ryckman KK, Gruca TS. Closure of Labor & Delivery units in rural counties is associated with reduced adequacy of prenatal care, even when prenatal care remains available. J Rural Health 2023; 39:746-755. [PMID: 36999217 DOI: 10.1111/jrh.12758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
PURPOSE Closure of rural Labor & Delivery (L&D) units can impact timely access to hospital-based obstetrical care. Iowa has lost over a quarter of its L&D units in the previous decade. Assessing the effect of these closures on prenatal care in those rural communities is important to understanding the full effect of unit closures on maternal health care. METHODS Using birth certificate data in Iowa from 2017 to 2019, the initiation of prenatal care and adequacy of prenatal visits were assessed for 47 rural counties in Iowa. Of these, 7 experienced a closure of the only L&D unit between 1/1/2018 and 1/1/2019. The impact of these closures is modeled for all birthing parents and compared for Medicaid versus non-Medicaid recipients. FINDINGS All 7 counties that experienced the loss of their only L&D unit continued to have prenatal care services available. Experiencing a closure of an L&D unit was associated with a lower likelihood of overall adequate prenatal care but not significantly associated with a lower rate of first-trimester prenatal care utilization. Among Medicaid recipients of the communities where an L&D unit closed, there was an association of closure with both a lower likelihood of adequate prenatal care and entry to prenatal care after the first trimester. CONCLUSIONS Utilization of prenatal care is lower in rural communities following L&D unit closure, especially among Medicaid recipients. This suggests that the overall maternal health systems were disrupted by the closure of the L&D unit, impacting the utilization of services that remained available to the community.
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Affiliation(s)
- Stephanie M Radke
- Department of Obstetrics & Gynecology, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Laurel Smeins
- Department of Internal Medicine, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Kelli K Ryckman
- University of Indiana School of Public Health, Iowa City, Iowa, USA
| | - Thomas S Gruca
- Tippie College of Business, University of Iowa, Iowa City, Iowa, USA
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9
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Holman C, Glover A, Fertaly K, Nelson M. Operationalizing risk-appropriate perinatal care in a rural US State: directions for policy and practice. BMC Health Serv Res 2023; 23:601. [PMID: 37291539 DOI: 10.1186/s12913-023-09552-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 05/15/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Risk-appropriate care improves outcomes by ensuring birthing people and infants receive care at a facility prepared to meet their needs. Perinatal regionalization has particular importance in rural areas where pregnant people might not live in a community with a birthing facility or specialty care. Limited research focuses on operationalizing risk-appropriate care in rural and remote settings. Through the implementation of the Centers for Disease Control and Prevention (CDC) Levels of Care Assessment Tool (LOCATe), this study assessed the system of risk-appropriate perinatal care in Montana. METHODS Primary data was collected from Montana birthing facilities that participated in the CDC LOCATe version 9.2 (collected July 2021 - October 2021). Secondary data included 2021 Montana birth records. All birthing facilities in Montana received an invitation to complete LOCATe. LOCATe collects information on facility staffing, service delivery, drills, and facility-level statistics. We added additional questions on transport. RESULTS Nearly all (96%) birthing facilities in Montana completed LOCATe (N = 25). The CDC applied its LOCATe algorithm to assign each facility with a level of care that aligns directly with guidelines published by the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG), and Society for Maternal-Fetal Medicine (SMFM). LOCATe-assessed levels for neonatal care ranged from Level I to Level III. Most (68%) facilities LOCATe-assessed at Level I or lower for maternal care. Close to half (40%) self-reported a higher-level of maternal care than their LOCATe-assessed level, indicating that many facilities believe they have greater capacity than outlined in their LOCATe-assessed level. The most common ACOG/SMFM requirements contributing to the maternal care discrepancies were the lack of obstetric ultrasound services and a physician anesthesiologist. CONCLUSIONS The Montana LOCATe results can drive broader conversations on the staffing and service requirements necessary to provide high-quality obstetric care in low-volume rural hospitals. Montana hospitals often rely on Certified Registered Nurse Anesthetists (CRNA) for anesthesia services and telemedicine to access specialty providers. Integrating a rural health perspective into the national guidelines could enhance the utility of LOCATe to support state strategies to improve the provision of risk-appropriate care.
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Affiliation(s)
- Carly Holman
- Rural Institute for Inclusive Communities, University of Montana, Missoula, MT, USA.
| | - Annie Glover
- Rural Institute for Inclusive Communities, University of Montana, Missoula, MT, USA
- School of Public and Community Health Sciences, University of Montana, Missoula, MT, USA
| | - Kaitlin Fertaly
- Rural Institute for Inclusive Communities, University of Montana, Missoula, MT, USA
| | - Megan Nelson
- Rural Institute for Inclusive Communities, University of Montana, Missoula, MT, USA
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10
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Thorsen ML, Harris S, Palacios JF, McGarvey RG, Thorsen A. American Indians travel great distances for obstetrical care: Examining rural and racial disparities. Soc Sci Med 2023; 325:115897. [PMID: 37084704 PMCID: PMC10164064 DOI: 10.1016/j.socscimed.2023.115897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/20/2023] [Accepted: 04/06/2023] [Indexed: 04/23/2023]
Abstract
Rural, American Indian/Alaska Native (AI/AN) people, a population at elevated risk for complex pregnancies, have limited access to risk-appropriate obstetric care. Obstetrical bypassing, seeking care at a non-local obstetric unit, is an important feature of perinatal regionalization that can alleviate some challenges faced by this rural population, at the cost of increased travel to give birth. Data from five years (2014-2018) of birth certificates from Montana, along with the 2018 annual survey of the American Hospital Association (AHA) were used in logistic regression models to identify predictors of bypassing, with ordinary least squares regression models used to predict factors associated with the distance (in miles) birthing people drove beyond their local obstetric unit to give birth. Logit analyses focused on hospital-based births to Montana residents delivered during this time period (n = 54,146 births). Distance analyses focused on births to individuals who bypassed their local obstetric unit to deliver (n = 5,991 births). Individual-level predictors included maternal sociodemographic characteristics, location, perinatal health characteristics, and health care utilization. Facility-related measures included level of obstetric care of the closest and delivery hospitals, and distance to the closest hospital-based obstetric unit. Findings suggest that birthing people living in rural areas and on American Indian reservations were more likely to bypass to give birth, with bypassing likelihood depending on health risk, insurance, and rurality. AI/AN and reservation-dwelling birthing people traveled significantly farther when bypassing. Findings highlight that distance traveled was even farther for AI/AN people facing pregnancy health risks (23.8 miles farther than White people with pregnancy risks) or when delivering at facilities offering complex care (14-44 miles farther than White people). While bypassing may connect rural birthing people to more risk-appropriate care, rural and racial inequities in access persist, with rural, reservation-dwelling AI/AN birthing people experiencing greater likelihood of bypassing and traveling greater distances when bypassing.
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Affiliation(s)
- Maggie L Thorsen
- Department of Sociology and Anthropology, Montana State University, USA.
| | - Sean Harris
- Jake Jabs College of Business and Entrepreneurship, Montana State University, USA
| | - Janelle F Palacios
- Department of Obstetrics and Gynecology, Kaiser Permanente Northern California, Oakland, California, 94611, USA
| | - Ronald G McGarvey
- IESEG School of Management, Univ. Lille, CNRS, UMR 9221 - LEM - Lille Economie Management, F-59000, Lille, France
| | - Andreas Thorsen
- Jake Jabs College of Business and Entrepreneurship, Montana State University, USA
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11
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Hoffmann J, Dresbach T, Hagenbeck C, Scholten N. Factors associated with the closure of obstetric units in German hospitals and its effects on accessibility. BMC Health Serv Res 2023; 23:342. [PMID: 37020222 PMCID: PMC10077609 DOI: 10.1186/s12913-023-09204-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/20/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND An increase in regionalization of obstetric services is being observed worldwide. This study investigated factors associated with the closure of obstetric units in hospitals in Germany and aimed to examine the effect of obstetric unit closure on accessibility of obstetric care. METHODS Secondary data of all German hospital sites with an obstetrics department were analyzed for 2014 and 2019. Backward stepwise regression was performed to identify factors associated with obstetrics department closure. Subsequently, the driving times to a hospital site with an obstetrics department were mapped, and different scenarios resulting from further regionalization were modelled. RESULTS Of 747 hospital sites with an obstetrics department in 2014, 85 obstetrics departments closed down by 2019. The annual number of live births in a hospital site (OR = 0.995; 95% CI = 0.993-0.996), the minimal travel time between two hospital sites with an obstetrics department (OR = 0.95; 95% CI = 0.915-0.985), the availability of a pediatrics department (OR = 0.357; 95% CI = 0.126-0.863), and population density (low vs. medium OR = 0.24; 95% CI = 0.09-0.648, low vs. high OR = 0.251; 95% CI = 0.077-0.822) were observed to be factors significantly associated with the closure of obstetrics departments. Areas in which driving times to the next hospital site with an obstetrics department exceeded the 30 and 40 min threshold slightly increased from 2014 to 2019. Scenarios in which only hospital sites with a pediatrics department or hospital sites with an annual birth volume of ≥ 600 were considered resulted in large areas in which the driving times would exceed the 30 and 40 min threshold. CONCLUSION Close distances between hospital sites and the absence of a pediatrics department at the hospital site associate with the closure of obstetrics departments. Despite the closures, good accessibility is maintained for most areas in Germany. Although regionalization may ensure high-quality care and efficiency, further regionalization in obstetrics will have an impact on accessibility.
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Affiliation(s)
- Jan Hoffmann
- Faculty of Medicine and University Hospital Cologne, Faculty of Human Sciences, Institute for Medical Sociology, Health Services Research, and Rehabilitation Science (IMVR), University of Cologne, Eupener Str. 129, 50933, Cologne, Germany.
| | - Till Dresbach
- University Hospital Bonn, Department of Neonatology and Pediatric Intensive Care Medicine, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Carsten Hagenbeck
- Department of Obstetrics and Gynecology, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Nadine Scholten
- Faculty of Medicine and University Hospital Cologne, Faculty of Human Sciences, Institute for Medical Sociology, Health Services Research, and Rehabilitation Science (IMVR), University of Cologne, Eupener Str. 129, 50933, Cologne, Germany
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12
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Carrel M, Keino BC, Novak NL, Ryckman KK, Radke S. Bypassing of nearest labor & delivery unit is contingent on rurality, wealth, and race. Birth 2023; 50:5-10. [PMID: 36752116 DOI: 10.1111/birt.12712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 01/02/2023] [Accepted: 01/13/2023] [Indexed: 02/09/2023]
Abstract
Patient decisions to bypass the closest labor & delivery (L&D) facility in favor of other birthing locations can have consequences for the provision of health care in rural and micropolitan areas as patient volumes decline and payer mixes change. Among 220 589 uncomplicated births in Iowa, we document characteristics of birth parents who bypass their closest birthing facility, show how this bypassing behavior results in changed travel times to delivery facilities across the rural/urban divide, and indicate the parts of the state where bypassing behavior is most prevalent. From 2013 to 2019, 55.2% of deliveries occurred in facilities that were further from birthing parents' residences than the closest L&D facility. Bypassing is associated with White, non-Hispanic race/ethnicity, and private insurance status. Although bypassing is least common among micropolitan birth parents, this group has the greatest travel burden to birthing facilities and exhibits increasing rates of bypassing over time. Perinatal quality improvement programs can target locations and populations where low-risk birthing parents can be encouraged to deliver close to home if medically appropriate, particularly in small towns and rural areas. This can potentially alleviate the risk of obstetric deserts by ensuring L&D units maintain patient volumes necessary to continue operations.
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Affiliation(s)
- Margaret Carrel
- Department of Geographical & Sustainability Sciences, University of Iowa, Iowa City, Iowa, USA.,Department of Epidemiology, University of Iowa, Iowa City, Iowa, USA
| | - Barbara C Keino
- Department of Geographical & Sustainability Sciences, University of Iowa, Iowa City, Iowa, USA
| | - Nicole L Novak
- Department of Community & Behavioral Health, University of Iowa, Iowa City, Iowa, USA
| | - Kelli K Ryckman
- Department of Epidemiology, University of Iowa, Iowa City, Iowa, USA
| | - Stephanie Radke
- Department of Obstetrics & Gynecology, University of Iowa, Iowa City, Iowa, USA
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Carrel M, Keino BC, Ryckman KK, Radke S. Labor & delivery unit closures most impact travel times to birth locations for micropolitan residents in Iowa. J Rural Health 2023; 39:113-120. [PMID: 34978349 DOI: 10.1111/jrh.12643] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE Continued closure of rural hospitals and labor & delivery units can impact timely access to care. Iowa has lost over a quarter of its labor & delivery units in the previous decade. Calculating how travel times to labor & delivery services have changed, and where in the state the largest travel times take place, are important for understanding access to this critical service. METHODS Using parental address and facility location from birth certificate data in Iowa from 2013 to 2019, travel times to birth facility are assessed for rural, micropolitan, and metropolitan parents, as well as for complicated versus noncomplicated births and Medicaid versus non-Medicaid recipients. FINDINGS Parts of the state have travel times that are consistently greater than 30 minutes over the duration of the study. The largest increases in travel times are found among micropolitan residents, particularly those experiencing complicated births. Travel times are consistently the longest for rural residents but increased only slightly over the study time period. CONCLUSIONS These findings suggest that access to hospital-based obstetric care is most changed for residents of small towns rather than rural or larger city residents.
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Affiliation(s)
- Margaret Carrel
- Department of Geographical & Sustainability Sciences, University of Iowa, Iowa City, Iowa, USA.,Department of Epidemiology, University of Iowa, Iowa City, Iowa, USA
| | - Barbara C Keino
- Department of Geographical & Sustainability Sciences, University of Iowa, Iowa City, Iowa, USA
| | - Kelli K Ryckman
- Department of Epidemiology, University of Iowa, Iowa City, Iowa, USA
| | - Stephanie Radke
- Department of Obstetrics & Gynecology, University of Iowa, Iowa City, Iowa, USA
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Basile Ibrahim B, Kozhimannil KB. Racial Disparities in Respectful Maternity Care During Pregnancy and Birth After Cesarean in Rural United States. J Obstet Gynecol Neonatal Nurs 2023; 52:36-49. [PMID: 36400125 PMCID: PMC9839498 DOI: 10.1016/j.jogn.2022.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/24/2022] [Accepted: 10/26/2022] [Indexed: 11/17/2022] Open
Abstract
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.
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15
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Rhoades CA, Whitacre BE, Davis AF. Community sociodemographics and rural hospital survival. J Rural Health 2022. [DOI: 10.1111/jrh.12728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Affiliation(s)
- Claudia A. Rhoades
- Department of Agricultural Economics Oklahoma State University Stillwater Oklahoma USA
| | - Brian E. Whitacre
- Department of Agricultural Economics Oklahoma State University Stillwater Oklahoma USA
| | - Alison F. Davis
- Department of Agricultural Economics University of Kentucky Lexington Kentucky USA
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16
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Association of Driving Distance to Maternity Hospitals and Maternal and Perinatal Outcomes. Obstet Gynecol 2022; 140:812-819. [DOI: 10.1097/aog.0000000000004960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 06/09/2022] [Indexed: 11/05/2022]
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17
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Friedman HR, Holmes GM. Rural Medicare beneficiaries are increasingly likely to be admitted to urban hospitals. Health Serv Res 2022; 57:1029-1034. [PMID: 35773787 PMCID: PMC9441274 DOI: 10.1111/1475-6773.14017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To determine whether rural Medicare FFS beneficiaries are more likely to be admitted to an urban hospital in 2018 than in 2010. DATA SOURCES We combined data from the 2010 to 2018 Hospital Service Area File (HSAF) and the 2010-2017 American Hospital Association (AHA) survey. STUDY DESIGN We conducted a fixed-effects negative-binomial regression to determine whether urban hospital admissions from rural ZIP codes were increasing over time. We also conducted an exploratory geographically weighted regression. DATA COLLECTION We transformed the HSAF data into a ZIP code-level file with all rural ZIP codes. We defined rural as having a Rural-Urban Commuting Area (RUCA) code ≥4. A hospital's system affiliation status was incorporated from the AHA survey. PRINCIPAL FINDINGS Controlling for distance to the nearest hospitals, an increase of 1 year was associated with a 2.0% increase (p < 0.001) in the number of admissions to urban hospitals from each rural ZIP code. New system affiliation of the nearest rural hospital was associated with an increase of 1.7% (p < 0.001). CONCLUSIONS Even when controlling for distance to the nearest rural hospital (which reflects hospital closures), rural patients were increasingly likely to be admitted to an urban hospital.
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Affiliation(s)
- Hannah R. Friedman
- Department of Health Policy and Management, Gillings School of Global Public HealthUniversity of North CarolinaChapel HillNorth CarolinaUSA
- The Cecil G. Sheps Center for Health Services ResearchThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - George Mark Holmes
- Department of Health Policy and Management, Gillings School of Global Public HealthUniversity of North CarolinaChapel HillNorth CarolinaUSA
- The Cecil G. Sheps Center for Health Services ResearchThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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DeSisto CL, Goodman DA, Brantley MD, Menard MK, Declercq E. Examining the Ratio of Obstetric Beds to Births, 2000-2019. J Community Health 2022; 47:828-834. [PMID: 35771384 PMCID: PMC11036083 DOI: 10.1007/s10900-022-01116-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2022] [Indexed: 11/24/2022]
Abstract
The number of U.S. births has been declining. There is also concern about rural obstetric units closing. To better understand the relationship between births and obstetric beds during 2000-2019, we examined changes over time in births, birth hospital distributions (i.e., hospital birth volume, ownership, and urban-rural designation), and the ratio of births to obstetric beds. We analyzed American Hospital Association Annual Survey data from 2000 to 2019. We included U.S. hospitals with at least 25 reported births during the year and at least 1 reported obstetric bed. We categorized birth volume to identify and describe hospitals with maternity services using seven categories. We calculated ratios of number of births to number of obstetric beds overall, by annual birth volume category, by three categories of hospital ownership, and by six urban-rural categories. The ratio of births to obstetric beds, which may represent need for maternity services, has stayed relatively consistent at 65 over the past two decades, despite the decline in births and changes in birth hospital distributions. The ratios were smallest in hospitals with < 250 annual births and largest in hospitals with ≥ 7000 annual births. The largest ratios of births to obstetric beds were in large metro areas and the smallest ratios were in noncore areas. At a societal level, the reduction in obstetric beds corresponds with the drop in the U.S. birth rate. However, consistency in the overall ratio can mask important differences that we could not discern, such as the impact of closures on distances to closest maternity care.
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Affiliation(s)
- Carla L DeSisto
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mailstop S107-2, Chamblee, GA, 30341, USA.
| | - David A Goodman
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mailstop S107-2, Chamblee, GA, 30341, USA
| | - Mary D Brantley
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mailstop S107-2, Chamblee, GA, 30341, USA
| | - M Kathryn Menard
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, 321 S Columbia St, Chapel Hill, NC, 27599, USA
| | - Eugene Declercq
- Community Health Sciences, Boston University School of Public Health, 715 Albany St, Boston, MA, 02118, USA
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Deutchman M, Macaluso F, Bray E, Evans D, Boulger J, Quinn K, Pierce C, Onello E, Porter J, Warren W, Erickson JS, Bright P, Maness P, Luke S, James KA. The impact of family physicians in rural maternity care. Birth 2022; 49:220-232. [PMID: 34558093 DOI: 10.1111/birt.12591] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/06/2021] [Accepted: 09/07/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Reduced access to maternity care in rural areas of the United States presents a significant burden to pregnant persons and infants. The objective of this study was to estimate the impact of family physicians (FPs) on access to maternity care in rural United States hospitals, especially where other providers may not be available. METHODS We administered a survey to 216 rural hospitals in 10 US states inquiring about the number of babies delivered from 2013 to 2017, the types of delivering physicians, and the maternity services offered. We calculated the percentage of rural hospitals in our sample where FPs performed vaginal deliveries, cesareans, and vaginal births after cesarean (VBACs), and the percentage of all babies delivered by FPs. We estimated the distance patients would have to travel for care if FPs were not providing care locally. RESULTS The final study population consisted of 185 rural hospitals. FPs delivered babies in 67% of these hospitals and were the only physicians who delivered babies in 27% of these hospitals. FPs provided VBAC at 18% and cesarean birth services at 46% of the rural hospitals, but with wide geographic differences. Many patients would have to drive an average of 86 miles round-trip to access care if those FPs were to stop delivering. CONCLUSIONS Family physicians are essential providers of maternity care in the rural United States. Family Medicine residency programs should ensure that trainees who intend to practice in rural locations have adequate maternity care training to maintain and expand access to maternity care for rural patients and their families.
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Affiliation(s)
- Mark Deutchman
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Francesca Macaluso
- Department of Environmental and Occupational Health, University of Colorado School of Public Health, Aurora, Colorado, USA
| | - Emily Bray
- Department of Family Medicine, East Carolina University Brody School of Medicine, Greenville, North Carolina, USA
| | - David Evans
- Department of Family Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - James Boulger
- Department of Family Medicine and Biobehavioral Health, University of Minnesota Duluth Medical School, Duluth, Minnesota, USA
| | - Kathleen Quinn
- University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Carrie Pierce
- Department of Family Medicine, Oregon Health and Science University School of Medicine and Faculty, Portland, Oregon, USA.,Cascades East Family Medicine Residency, Klamath Falls, Oregon, USA
| | - Emily Onello
- Department of Family Medicine and Biobehavioral Health, University of Minnesota Duluth Medical School, Duluth, Minnesota, USA
| | - Jana Porter
- University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Wendy Warren
- Department of Family Medicine, Oregon Health and Science University School of Medicine and Faculty, Portland, Oregon, USA.,Cascades East Family Medicine Residency, Klamath Falls, Oregon, USA
| | - Jay S Erickson
- Department of Family Medicine, University of Washington School of Medicine, Seattle, Washington, USA.,WWAMI Montana, University of Washington School of Medicine, Seattle, Washington, USA
| | - Patrick Bright
- Department of Family Medicine and Biobehavioral Health, University of Minnesota Duluth Medical School, Duluth, Minnesota, USA
| | - Philip Maness
- Department of Family Medicine, East Carolina University Brody School of Medicine, Greenville, North Carolina, USA
| | - Shanon Luke
- University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Katherine A James
- Department of Environmental and Occupational Health, University of Colorado School of Public Health, Aurora, Colorado, USA
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Min HS, Kim S, Kim S, Lee T, Kim SY, Ahn HS, Choe SA. Is limited access to obstetric services associated with adverse birth outcomes? A cross-sectional study of Korean national birth data. BMJ Open 2022; 12:e056634. [PMID: 35589342 PMCID: PMC9121485 DOI: 10.1136/bmjopen-2021-056634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES The geographical disparity in the access to essential obstetric services is a public health issue in many countries. We explored the association between timely access to obstetric services and the individual risk of adverse birth outcomes. DESIGN Repeated cross-sectional design. SETTING South Korean national birth data linked with a medical service provision database. PARTICIPANTS 1 842 718 singleton livebirths from 2014 to 2018. PRIMARY OUTCOME MEASURES Preterm birth (PTB), post-term birth, low birth weight (LBW) and macrosomia. RESULTS In the study population, 9.3% of mothers lived in districts where the Time Relevance Index (TRI) was as low as the first quartile (40.6%). Overall PTB and post-term birth rates were 5.0% and 0.1%, respectively. Among term livebirths, LBW and macrosomia occurred in 1.0% and 3.3%, respectively. When the TRI is lower, representing less access to obstetric care, the risk of macrosomia was higher (adjusted OR=1.15, 95% CI 1.11 to 1.20 for Q1 compared with Q4). Similarly, PTB is more likely to occur when TRI is lower (1.05, 95% CI 1.00 to 1.10 for Q1; 1.03, 95% CI 1.01 to 1.05 for Q2). There were some inverse associations between TRI and post-term birth (0.80, 95% CI 0.71 to 0.91, for Q2; 0.84, 95% CI 0.76 to 0.93, for Q3). CONCLUSIONS We observed less accessibility to obstetric service is associated with higher risks of macrosomia and PTB. This finding supports the role of obstetric service accessibility in the individual risk of adverse birth outcomes.
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Affiliation(s)
- Hye Sook Min
- Research Institute of Public Healthcare, National Medical Center, Seoul, Korea
| | - Saerom Kim
- Research Institute of Public Healthcare, National Medical Center, Seoul, Korea
- Gender and Health Research Center, People's Health Institute, Seoul, Korea
| | - Seulgi Kim
- Public Health Science, Seoul National University Graduate School of Public Health, Seoul, Korea
| | - Taeho Lee
- Public Healthcare Policy, National Medical Center, Seoul, Korea
| | - Sun-Young Kim
- Cancer Control and Population Health, National Cancer Center, Goyang, Gyeonggi-do, Korea
| | - Hyeong Sik Ahn
- Preventive Medicine, Korea University-Anam Campus, Seongbuk-gu, Seoul, Korea
| | - Seung-Ah Choe
- Preventive Medicine, Korea University-Anam Campus, Seongbuk-gu, Seoul, Korea
- Division of Life Sciences, Korea University, Seongbuk-gu, Seoul, Korea
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21
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Way EA, Carwile JL, Ziller EC, Ahrens KA. Out-of-hospital births and infant mortality in the United States: Effect measure modification by rural maternal residence. Paediatr Perinat Epidemiol 2022; 36:399-411. [PMID: 35108404 DOI: 10.1111/ppe.12862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 11/22/2021] [Accepted: 12/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Out-of-hospital births have been increasing in the United States, and home births are almost twice as common in rural vs. urban counties. Planned home births and births in rural areas have each been associated with an increased risk of infant mortality. OBJECTIVES To estimate the effect of birth setting on infant mortality in the United States and how this is modified by rural-urban county of maternal residence. METHODS We conducted a population-based cohort study of infants born in the United States during 2010-2017 using the National Center for Health Statistics' period-linked birth-infant death files. Unadjusted and adjusted Poisson regression models were used to calculate infant mortality rate ratios and 95% confidence intervals for out-of-hospital births vs. hospital births stratified by maternal residence. Relative excess risk due to interaction (RERI) was calculated to assess effect measure modification on the additive scale. RESULTS The study included 25,210,263 live births. Of rural births, 97.8% was in hospitals, 0.5% was in birth centres, and 1.5% was planned home births; of urban births, 98.6% was in hospitals, 0.5% was in birth centres, and 0.7% was planned home births. After adjusting for maternal demographics and markers of high-risk pregnancy and stratifying by maternal residence, infant mortality rates were generally higher for out-of-hospital as compared to hospital births (e.g. rural planned home births aRR 1.62, 95% confidence interval [CI] 1.42, 1.85, and rural birth centre aRR 1.33, 95% CI 1.05, 1.68). There were positive additive effects of rural residence on infant mortality for planned home births and birth centre births. CONCLUSIONS Within both rural and urban areas, out-of-hospital births generally had higher rates of infant mortality than hospital births after accounting for maternal demographics and markers of high-risk pregnancy. The risks associated with planned home births and birth centre births were more pronounced for women in rural counties.
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Affiliation(s)
- Elora A Way
- The Muskie School of Public Service, University of Southern Maine, Portland, Maine, USA
| | - Jenny L Carwile
- The Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, Maine, USA
| | - Erika C Ziller
- The Muskie School of Public Service, University of Southern Maine, Portland, Maine, USA
| | - Katherine A Ahrens
- The Muskie School of Public Service, University of Southern Maine, Portland, Maine, USA
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22
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Carroll C, Interrante JD, Daw JR, Kozhimannil KB. Association Between Medicaid Expansion And Closure Of Hospital-Based Obstetric Services. Health Aff (Millwood) 2022; 41:531-539. [PMID: 35377761 DOI: 10.1377/hlthaff.2021.01478] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Access to obstetric services has declined steadily during the past decade, driven by the closure of hospital-based obstetric units and of entire hospitals. A fundamental challenge to maintaining obstetric services is that they are frequently unprofitable for hospitals to operate, threatening hospital viability. Medicaid expansion has emerged as a possible remedy for obstetric service closure because it reduces uncompensated care and improves hospital finances. Using national hospital data from the period 2010-18, we assessed the relationship between Medicaid expansion and obstetric service closure in rural and urban communities. We found that expansion led to a large reduction in hospital closures; however, this effect was concentrated among hospitals that did not have obstetric units. Considering closure of obstetric units, we found that rural obstetric units were less likely to close immediately after expansion, but this effect faded within two years. Overall, our findings suggest that Medicaid expansion had little effect on the closure of obstetric services. Policies supporting access to obstetric care may need to directly address the financial challenges specific to this service line.
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Affiliation(s)
- Caitlin Carroll
- Caitlin Carroll , University of Minnesota, Minneapolis, Minnesota
| | | | - Jamie R Daw
- Jamie R. Daw, Columbia University, New York, New York
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Orrantia E, Hutten-Czapski P, Mercier M, Fageria S. Northern Ontario's Obstetrical Services in 2020: A developing rural maternity care desert. CANADIAN JOURNAL OF RURAL MEDICINE 2022; 27:61-68. [PMID: 35343183 DOI: 10.4103/cjrm.cjrm_4_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction Rural maternity care services matter. Obstetrical care in rural Canada has seen concerning trends of service closures and decreasing numbers of family physicians who predominantly provide this service. Such reductions have been shown to have a serious impact on maternal/foetal well-being. Methods This study investigated the present state of obstetrical services in Northern Ontario, comparing results to those of the last similar survey in 1999. All 40 Northern Ontario communities with hospitals were surveyed, as were the 16 midwife practices in the region. Results : Of the 35 rural and 5 urban hospitals surveyed, the number not offering obstetrical care has risen from 37.5% in 1999 to 60% in 2020, with all the closures having been rural sites. There have been no re-openings of obstetrics in hospitals that did not offer obstetrics in 1999. Women in the 9 communities that had offered maternity services in 1999, but no longer do in 2020, now travel an average of over 1.5 h to access these services. In those communities that continue obstetrics, but stopped offering caesarean sections, women now travel 2.5 h for this surgery. Although the total number of general physicians remains at the 1999 level, the number offering intrapartum care has dropped by 65% in urban centres and by 49% in rural ones still providing maternity care. Conclusions Like much of the rural United States, rural Northern Ontario is well on its way to becoming a maternity care desert. As proven in Southern Australia, supportive government policies and programmes should be established and education reform enacted to reverse this concerning trend.
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Affiliation(s)
- Eliseo Orrantia
- Division of Clinical Sciences, Northern Ontario School of Medicine, Marathon, Ontario, Canada
| | - Peter Hutten-Czapski
- Division of Clinical Sciences, Northern Ontario School of Medicine, Haileybury, Ontario, Canada
| | - Mathieu Mercier
- Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Samarth Fageria
- Faculty of Medicine, Memorial University, St. Johns, Newfoundland and Labrador, Canada
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Lowman GH, Harms PD. Editorial: Addressing the nurse workforce crisis: a call for greater integration of the organizational behavior, human resource management and nursing literatures. JOURNAL OF MANAGERIAL PSYCHOLOGY 2022. [DOI: 10.1108/jmp-04-2022-713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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25
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Daymude AEC, Daymude JJ, Rochat R. Labor and Delivery Unit Closures in Rural Georgia from 2012 to 2016 and the Impact on Black Women: A Mixed-Methods Investigation. Matern Child Health J 2022; 26:796-805. [PMID: 35182306 DOI: 10.1007/s10995-022-03380-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Anna E Carson Daymude
- Rollins School of Public Health, Emory University, Grace Crum Rollins Building 1518 Clifton Rd., Atlanta, GA, 30322, USA.
| | - Joshua J Daymude
- Biodesign Center for Biocomputing, Security and Society, Arizona State University, 727 E. Tyler St., Tempe, AZ, 85281, USA
| | - Roger Rochat
- Rollins School of Public Health, Emory University, Grace Crum Rollins Building 1518 Clifton Rd., Atlanta, GA, 30322, USA
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Uribe-Leitz T, Matsas B, Dalton MK, Lutgendorf MA, Moberg E, Schoenfeld AJ, Goralnick E, Weissman JS, Hamlin L, Cooper Z, Koehlmoos TP, Jarman MP. Geospatial Analysis of Access to Emergency Cesarean Delivery for Military and Civilian Populations in the US. JAMA Netw Open 2022; 5:e2142835. [PMID: 35006244 PMCID: PMC8749478 DOI: 10.1001/jamanetworkopen.2021.42835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Many women in the US, particularly those living in rural areas, have limited access to obstetric care. Military-civilian partnership could improve access to obstetric care and benefit military personnel, their civilian dependents, and the civilian population as a whole. OBJECTIVE To identify medical facilities within military and civilian geographic areas that present opportunities for military-civilian partnership in obstetric care and to assess whether civilian use of military medical treatment facilities (MTFs) could improve access to emergency cesarean delivery care in the US. DESIGN, SETTING, AND PARTICIPANTS This geospatial epidemiological population-based cross-sectional study was conducted from November 2020 to March 2021. ArcGIS Pro software, version 2.7 (Esri), was used to assess population coverage for TRICARE (military insurance) beneficiaries and civilian populations and to estimate 30-minute travel time to 2392 total military and civilian medical facilities that were capable of providing emergency cesarean delivery care in the continental US. Data on health insurance coverage for TRICARE beneficiaries and their civilian dependents per county were obtained from the American Community Survey tables available through ArcGIS Pro software. Demographic characteristics of the general population were obtained from the 2020 key demographic indicators published by Esri. Race and ethnicity were not examined because the data used for this study were aggregated and did not include further categorization by race or ethnicity. MAIN OUTCOMES AND MEASURES Population coverage rates (measured in percentages) within 30-minute catchment areas, defined as areas that were within a 30-minute travel time to a medical facility capable of providing emergency cesarean delivery care. RESULTS A total of 29 MTFs and 2363 civilian hospitals capable of providing emergency cesarean delivery were identified across the contiguous US. Overall, an estimated 167 759 762 women (3 640 000 TRICARE beneficiaries and 164 119 762 civilians) were included in these service areas. The analysis identified 17 of 29 MTFs (58.6%) capable of providing emergency cesarean delivery care that were located within 30-minute catchment areas. Of those, 3 MTFs were the only facilities capable of providing emergency cesarean delivery care within a 30-minute travel time in those regions, and 14 additional MTFs had catchment areas partially overlapping with civilian hospitals that also covered areas without alternative access to emergency cesarean delivery. Expanded use of these 14 MTFs could enhance access to emergency cesarean delivery care not otherwise covered by current civilian hospitals. CONCLUSIONS AND RELEVANCE In this study, 58.6% of MTFs capable of providing emergency cesarean delivery care were located in areas with the potential to improve access to obstetric care within a 30-minute travel time. Maintenance of MTFs in these important access regions could be prioritized in the context of restructuring MTFs. This prioritization has the potential to improve access to emergency cesarean delivery care for underserved civilian populations in the US, particularly among those living in rural areas.
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Affiliation(s)
- Tarsicio Uribe-Leitz
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts
- Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | | | - Michael K. Dalton
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Monica A. Lutgendorf
- Division of Maternal-Fetal Medicine, Naval Medical Center San Diego, San Diego, California
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Esther Moberg
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Andrew J. Schoenfeld
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Eric Goralnick
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Joel S. Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Lynette Hamlin
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Zara Cooper
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Tracey P. Koehlmoos
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Molly P. Jarman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
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G. Button B, Taylor K, McArthur M, Newbery S, Cameron E. The economic impact of rural healthcare on rural economies: A rapid review. CANADIAN JOURNAL OF RURAL MEDICINE 2022; 27:158-168. [DOI: 10.4103/cjrm.cjrm_70_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Whittaker J, Kellom K, Matone M, Cronholm P. A Community Capitals Framework for Identifying Rural Adaptation in Maternal-Child Home Visiting. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2021; 27:E28-E36. [PMID: 31274703 DOI: 10.1097/phh.0000000000001042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To understand how maternal and child home-visiting programs are adapted, enhanced, and expanded to meet the unique needs of rural communities. DESIGN We explored factors shaping the role of home visiting with data from a 2013-2015 statewide evaluation of Maternal, Infant, and Early Childhood Home Visiting-funded programs. Features unique to a rural experiences were mapped onto the Community Capitals Framework. SETTING Individual, semistructured interviews were conducted at 11 of 38 home-visiting sites across Pennsylvania. PARTICIPANTS Program administrators, home visitors, and clients. MAIN OUTCOME MEASURE Program adaptation. RESULTS Our analysis represents 150 interviews with 11 program sites serving 14 counties. We document how rural home-visiting programs address community-wide limitations to maternal and child health by adapting program content to better meet the needs of families in rural areas. Data demonstrate how rural home-visiting program's provision of economic and social services reach beyond maternal child health care, building the capacity of individual families and the broader community. CONCLUSIONS Home-visiting programs should be viewed as a vehicle for improving community well-being beyond health outcomes. These programs have become an integral part of our public health framework and should be leveraged as such.
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Affiliation(s)
- Jennifer Whittaker
- Robert Wood Johnson Health Policy Research Scholars Program, Robert Wood Johnson Foundation, Princeton, New Jersey (Ms Whittaker); PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (Mss Whittaker and Kellom and Dr Matone); Department of City Planning, University of Pennsylvania School of Design, Philadelphia, Pennsylvania (Ms Whittaker); Departments of Pediatrics (Dr Matone) and Family Medicine and Community Health (Dr Cronholm), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, Pennsylvania (Drs Matone and Cronholm); and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (Ms Whittaker and Drs Matone and Cronholm)
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Markus AR, Pillai D. Mapping the Location of Health Centers in Relation to "Maternity Care Deserts": Associations With Utilization of Women's Health Providers and Services. Med Care 2021; 59:S434-S440. [PMID: 34524240 PMCID: PMC8428862 DOI: 10.1097/mlr.0000000000001611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES The aim was to explore the association between community health centers' (CHC) distance to a "maternity care desert" (MCD) and utilization of maternity-related health care services, controlling for CHC and county-level factors. MEASURES Utilization as: total number of CHC visits to obstetrician-gynecologists, certified nurse midwives, family physicians (FP), and nurse practitioners (NP); total number of prenatal care visits and deliveries performed by CHC staff. RESEARCH DESIGN Cross-sectional design comparing utilization between CHCs close to MCDs and those that were not, using linked 2017 data from the Uniform Data System (UDS), American Hospital Association Survey, and Area Health Resource Files. On the basis of prior research, CHCs close to a "desert" were hypothesized to provide higher numbers of FP and NP visits than obstetrician-gynecologists and certified nurse midwives visits. The sample included 1261 CHCs and all counties in the United States and Puerto Rico (n=3234). RESULTS Results confirm the hypothesis regarding NP visits but are mixed for FP visits. CHCs close to "deserts" had more NP visits than those that were not. There was also a dose-response effect by MCD classification, with NP visits 3 times higher at CHCs located near areas without any outpatient and inpatient access to maternity care. CONCLUSIONS CHCs located closer to "deserts" and NPs working at these comprehensive, primary care clinics have an important role to play in providing access to maternity care. More research is needed to determine how best to target resources to these limited access areas.
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Affiliation(s)
- Anne R. Markus
- Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University
| | - Drishti Pillai
- National Asian Pacific American Women’s Forum, Washington, DC
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Obstetrical unit closures and racial and ethnic differences in severe maternal morbidity in the state of New Jersey. Am J Obstet Gynecol MFM 2021; 3:100480. [PMID: 34496307 DOI: 10.1016/j.ajogmf.2021.100480] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 08/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND In the United States, racial disparities in maternal morbidity and mortality are pronounced and persistent. Although the maternal mortality ratio and the severe maternal morbidity rates have increased over the past 30 years, the number of obstetrical units in the country has simultaneously diminished. Black women are 3 times more likely to die during childbirth than White women and twice as likely to suffer severe maternal morbidity (or a near miss). Between 2003 and 2013, 366 (10%) obstetrical units closed, and rural obstetrical unit closures were more likely in the Black communities. The state of New Jersey has the highest Black maternal mortality rate (131.8/100,000 live births) of all states reporting these data. Very few studies have examined the role that urban obstetrical unit closures play in racial and ethnic disparities in maternal health outcomes. OBJECTIVE To analyze racial differences in severe maternal morbidity in New Jersey hospitals among women experiencing the loss of their nearest obstetrical unit during the years 2006-2015. STUDY DESIGN This study used data on all births in New Jersey hospitals (2006-2015) by women living in ZIP code tabulation areas that lost their nearest obstetrical unit during that period. Severe maternal morbidity was measured using a composite variable for severe illness during hospitalizations (eg, acute heart failure, acute renal disease, disseminated intravascular coagulation, sepsis) identified using the International Classification of Diseases, Ninth Revision. Logistic regression models were used to analyze the associations between race and ethnicity on the individual likelihood of severe maternal morbidity, adjusting for annual trends, individual socioeconomic characteristics, age, preexisting conditions, and delivery hospital characteristics (ie, percentage of Black patients >25% [Black-serving hospital] and percentage of Medicaid discharges in the delivery obstetrical unit). RESULTS There were 227,412 delivery hospitalizations among women who lived in the 124 New Jersey ZIP code tabulation areas that lost the nearest obstetrical unit from 2006 to 2015. Black women had the highest severe maternal morbidity rates, increasing from 1.2% in 2006 to 2.3% in 2015. The Black-White gap remained similar in magnitude over the period, as White women's severe maternal morbidity rates increased from 0.7% to 1.4%. However, for Hispanic women, the severe maternal morbidity increased dramatically from 0.7% in 2006 to 2.4% in 2013, followed by a decreasing trend during 2013-2015. When adjusting for individual factors, the odds of severe maternal morbidity among all women was greater if they delivered after the loss of the nearest obstetrical unit (adjusted odds ratio, 1.55; 95% confidence interval, 1.30-1.86). Hispanic women experienced the greatest increase in severe maternal morbidity, regardless of whether they delivered before or after the closure of their nearest obstetrical unit. For all women, delivering in a Black-serving obstetrical unit was associated with a greater likelihood of individual severe maternal morbidity (adjusted odds ratio, 1.36; 95% confidence interval, 1.19-1.56). CONCLUSION Racial and ethnic disparities in severe maternal morbidity persist and might be exacerbated by nearby obstetrical unit closures. In New Jersey ZIP codes with obstetrical unit loss, the Hispanic-White gap in the severe maternal morbidity widened substantially, and the rates were also higher among women who delivered in Black-serving hospitals. Policymakers should take steps to prevent obstetrical unit closures and to ensure that the resources available at Black-serving obstetrical units are at least on par with those of other institutions.
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Fischer AR, Green SRM, Gunn HE. Social-ecological considerations for the sleep health of rural mothers. J Behav Med 2021; 44:507-518. [PMID: 33083923 PMCID: PMC7574991 DOI: 10.1007/s10865-020-00189-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 09/30/2020] [Indexed: 02/03/2023]
Abstract
Using a social-ecological framework, we identify social determinants that interact to influence sleep health, identify gaps in the literature, and make recommendations for targeting sleep health in rural mothers. Rural mothers experience unique challenges and protective factors in maintaining adequate sleep health during the postpartum and early maternal years. Geographic isolation, barriers to comprehensive behavioral medicine services, and intra-rural ethno-racial disparities are discussed at the societal (e.g., public policy), social (e.g., community) and individual levels (e.g., stress) of the social-ecological model. Research on sleep health would benefit from attention to methodological considerations of factors affecting rural mothers such as including parity in population-level analyses or applying community-based participatory research principles. Future sleep health programs would benefit from using existing social support networks to disseminate sleep health information, integrating behavioral health services into clinical care frameworks, and tailoring culturally-appropriate Telehealth/mHealth programs to enhance the sleep health of rural mothers.
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Affiliation(s)
- Alexandra R Fischer
- Department of Psychology, University of Alabama, Box 87034, Tuscaloosa, AL, 35487, USA
| | | | - Heather E Gunn
- Department of Psychology, University of Alabama, Box 87034, Tuscaloosa, AL, 35487, USA.
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Handley SC, Passarella M, Srinivas SK, Lorch SA. Identifying individual hospital levels of maternal care using administrative data. BMC Health Serv Res 2021; 21:538. [PMID: 34074286 PMCID: PMC8171026 DOI: 10.1186/s12913-021-06516-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 05/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The goal of regionalized perinatal care, specifically levels of maternal care, is to improve maternal outcomes through risk-appropriate obstetric care. Studies of levels of maternal care are limited by current approaches to identify a hospital's level of care, often relying on hospital self-reported data, which is expensive and challenging to collect and validate. The study objective was to develop an empiric approach to determine a hospital's level of maternal care using administrative data reflective of the patient care provided and apply this approach to describe the levels of maternal care available over time. METHODS Retrospective cohort study of mother-infant dyads who delivered in California, Missouri, and Pennsylvania hospitals from 2000 to 2009. Linked mother-infant administrative records with an infant born at 24-44 weeks' gestation and a birth weight of 400-8000 g were included. Using the American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine descriptions of levels of maternal care, four levels were classified based on the appropriate location of care for patients with specific medical or pregnancy conditions. Individual hospitals were assigned a level of maternal care annually based on the volume of patients who delivered reflective of the four classified levels as determined by International Classification of Diseases and Current Procedural Terminology. RESULTS Based on the included 6,895,000 mother-infant dyads, the obstetric hospital levels of maternal care I, II, III and IV were identified. High-risk patients more frequently delivered in hospitals with higher level maternal care, accounting for 8.9, 10.9, 13.8, and 16.9% of deliveries in level I, II, III and IV hospitals, respectively. The total number of obstetric hospitals decreased over the study period, while the proportion of hospitals with high-level (level III or IV) maternal care increased. High-level hospitals were located in more densely populated areas. CONCLUSION Identification of the level of maternal care, independent of hospital self-reported variables, is feasible using administrative data. This empiric approach, which accounts for changes in hospitals over time, is a valuable framework for perinatal researchers and other stakeholders to inexpensively identify measurable benefits of levels of maternal care and characterize where specific patient populations receive care.
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Affiliation(s)
- Sara C Handley
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and the Perelman School of Medicine-University of Pennsylvania, Philadelphia, PA, USA. .,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Molly Passarella
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and the Perelman School of Medicine-University of Pennsylvania, Philadelphia, PA, USA
| | - Sindhu K Srinivas
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,The Maternal and Child Health Research Center, Department of Obstetrics and Gynecology and the Perelman School of Medicine-University of Pennsylvania, Philadelphia, PA, USA
| | - Scott A Lorch
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and the Perelman School of Medicine-University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Lorch SA, Rogowski J, Profit J, Phibbs CS. Access to risk-appropriate hospital care and disparities in neonatal outcomes in racial/ethnic groups and rural-urban populations. Semin Perinatol 2021; 45:151409. [PMID: 33931237 PMCID: PMC8184635 DOI: 10.1016/j.semperi.2021.151409] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Variations in infant and neonatal mortality continue to persist in the United States and in other countries based on both socio-demographic characteristics, such as race and ethnicity, and geographic location. One potential driver of these differences is variations in access to risk-appropriate delivery care. The purpose of this article is to present the importance of delivery hospitals on neonatal outcomes, discuss variation in access to these hospitals for high-risk infants and their mothers, and to provide insight into drivers for differences in access to high-quality perinatal care using the available literature. This review also illustrates the lack of information on a number of topics that are crucial to the development of evidence-based interventions to improve access to appropriate delivery hospital services and thus optimize the outcomes of high-risk mothers and their newborns.
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Affiliation(s)
- Scott A. Lorch
- Children's Hospital of Philadelphia, Division of Neonatology,Perelman School of Medicine, University of Pennsylvania
| | | | - Jochen Profit
- Stanford University School of Medicine, Department of Pediatrics, Division of Neonatal Medicine
| | - Ciaran S. Phibbs
- Stanford University School of Medicine, Department of Pediatrics, Division of Neonatal Medicine,Veterans Affairs Palo Alto Health Care System
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Efird CR, Dry D, Seidman RF. Loss of Obstetric Services in Rural Appalachia: A Qualitative Study of Community Perceptions. JOURNAL OF APPALACHIAN HEALTH 2021; 3:4-17. [PMID: 35769173 PMCID: PMC9192102 DOI: 10.13023/jah.0302.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background As rural hospitals across the United States increasingly downsize or close, the availability of inpatient obstetric services continues to decline in rural areas. In rural Appalachia, the termination of obstetric services threatens to exacerbate the existing risk of adverse birth outcomes for women and infants, yet less is known about how the cessation of these services affects the broader community. Purpose The purpose of this paper is to explain how the loss of local obstetric services affects perceptions of healthcare among multi-generational residents of a remote, rural Appalachian community in western North Carolina. Methods An interdisciplinary team of researchers conducted a thematic analysis of health-related oral history interviews (n=14) that were collected from local residents of a rural, western North Carolina community during the summer of 2019. Results The closure of a local hospital's labor and delivery department fostered (1) frustration with the decline in hospital services, (2) perceived increases in barriers to accessing healthcare, and (3) increased medical mistrust. Implications Findings suggest that the loss of obstetric services in this rural Appalachian community could have broad, negative health implications for all residents, regardless of their age, sex, or ability to bear children. Community-specific strategies are needed to foster trust in the remaining healthcare providers and to increase access to care for local residents. Results serve as formative research to support the development of interventions and policies that effectively respond to all community members' needs and concerns following the loss of obstetric services in remote Appalachian communities.
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Affiliation(s)
- Caroline R Efird
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - David Dry
- Department of History, University of North Carolina at Chapel Hill
| | - Rachel F Seidman
- Center for the Study of the American South, University of North Carolina at Chapel Hill
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Hannan KE, Bourque SL, Palmer C, Tong S, Hwang SS. Prevalence and Predictors of Medical Complexity in a National Sample of VLBW Infants. Hosp Pediatr 2021; 11:525-535. [PMID: 33906959 DOI: 10.1542/hpeds.2020-004945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Kathleen E Hannan
- Section of Neonatology, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Stephanie Lynn Bourque
- Section of Neonatology, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Claire Palmer
- Section of Neonatology, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Suhong Tong
- Section of Neonatology, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Sunah Susan Hwang
- Section of Neonatology, Department of Pediatrics, University of Colorado, Aurora, Colorado
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Carlough M, Chetwynd E, Muthler S, Page C. Maternity Units in Rural Hospitals in North Carolina: Successful Models for Staffing and Structure. South Med J 2021; 114:92-97. [PMID: 33537790 DOI: 10.14423/smj.0000000000001208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- Martha Carlough
- From the School of Medicine, the Department of Family Medicine, and the Department of Maternal and Child Health, Gilling School of Global Public Health, University of North Carolina, Chapel Hill
| | - Ellen Chetwynd
- From the School of Medicine, the Department of Family Medicine, and the Department of Maternal and Child Health, Gilling School of Global Public Health, University of North Carolina, Chapel Hill
| | - Sarah Muthler
- From the School of Medicine, the Department of Family Medicine, and the Department of Maternal and Child Health, Gilling School of Global Public Health, University of North Carolina, Chapel Hill
| | - Cristen Page
- From the School of Medicine, the Department of Family Medicine, and the Department of Maternal and Child Health, Gilling School of Global Public Health, University of North Carolina, Chapel Hill
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Hansen AC, Slavova S, O'Brien JM. Rural residency as a risk factor for severe maternal morbidity. J Rural Health 2021; 38:161-170. [PMID: 33682958 DOI: 10.1111/jrh.12567] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
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.
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Affiliation(s)
- Anna C Hansen
- University of Kentucky College of Medicine, Lexington, Kentucky, USA.,Kentucky Injury Prevention and Research Center, University of Kentucky, Lexington, Kentucky, USA
| | - Svetla Slavova
- Kentucky Injury Prevention and Research Center, University of Kentucky, Lexington, Kentucky, USA.,Department of Biostatistics, University of Kentucky, Lexington, Kentucky, USA
| | - John M O'Brien
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Kentucky, Lexington, Kentucky, USA
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Geographic access to critical care obstetrics for women of reproductive age by race and ethnicity. Am J Obstet Gynecol 2021; 224:304.e1-304.e11. [PMID: 32835715 DOI: 10.1016/j.ajog.2020.08.042] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/03/2020] [Accepted: 08/19/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The goal of risk-appropriate maternal care is for high-risk pregnant women to receive specialized obstetrical services in facilities equipped with capabilities and staffing to provide care or transfer to facilities with resources available to provide care. In the United States, geographic access to critical care obstetrics varies. It is unknown whether this variation in proximity to critical care obstetrics differs by race, ethnicity, and region. OBJECTIVE We examined the geographic access, defined as residence within 50 miles of a facility capable of providing risk-appropriate critical care obstetrics services for women of reproductive age, by distribution of race and ethnicity. STUDY DESIGN Descriptive spatial analysis was used to assess geographic distance to critical care obstetrics for women of reproductive age by race and ethnicity. Data were analyzed geographically: nationally, by the Department of Health and Human Services regions, and by all 50 states and the District of Columbia. Dot density analysis was used to visualize geographic distributions of women by residence and critical care obstetrics facilities across the United States. Proximity analysis defined the proportion of women living within an approximate 50-mile radius of facilities. Source data included the 2015 American Community Survey from the United States Census Bureau and the 2015 American Hospital Association Annual Survey. RESULTS Geographic access to critical care obstetrics was the greatest for Asian and Pacific Islander women of reproductive age (95.8%), followed by black (93.5%), Hispanic (91.4%), and white women of reproductive age (89.1%). American Indian and Alaska Native women had more limited geographic access (66%) in all regions. Visualization of proximity to critical care obstetrics indicated that facilities were predominantly located in urban areas, which may limit access to women in frontier or rural areas of states including nationally recognized reservations where larger proportions of white women and American Indian and Alaska Native women reside, respectively. CONCLUSION Disparities in proximity to critical care obstetrics exist in rural and frontier areas of the United States, which affect white women and American Indian and Alaska Native women, primarily. Examining insurance coverage, interstate hospital referral networks, and transportation barriers may provide further insight into critical care obstetrics accessibility. Further exploring the role of other equity-based measures of access on disparities beyond geography is warranted.
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Wang X, Whittaker J, Kellom K, Garcia S, Marshall D, Dechert T, Matone M. Integrating the Built and Social Environment into Health Assessments for Maternal and Child Health: Creating a Planning-Friendly Index. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E9224. [PMID: 33321736 PMCID: PMC7763863 DOI: 10.3390/ijerph17249224] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 11/17/2022]
Abstract
Environmental and community context earliest in the life course have a profound effect on life-long health outcomes. Yet, standard needs assessments for maternal and child health (MCH) programs often overlook the full range of influences affecting health in-utero and early childhood. To address this, we developed a methodology for assessing community risk in MCH based on six domains integrating 66 indicators across community, environment, socioeconomic indicators, and MCH outcomes. We pilot this methodology in Pennsylvania, and share examples of how local governments, planners, and public health officials across the geographic spectrum can integrate this data into community planning for improved maternal and child health.
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Affiliation(s)
| | | | | | | | | | | | - Meredith Matone
- PolicyLab at Children’s Hospital of Philadelphia, 2716 South Street, Philadelphia, PA 19146, USA; (X.W.); (J.W.); (K.K.); (S.G.); (D.M.); (T.D.)
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Lee H, Hirai AH, Lin CCC, Snyder JE. Determinants of rural-urban differences in health care provider visits among women of reproductive age in the United States. PLoS One 2020; 15:e0240700. [PMID: 33301492 PMCID: PMC7728245 DOI: 10.1371/journal.pone.0240700] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 10/01/2020] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Hyunjung Lee
- Oak Ridge Institute for Science and Education (ORISE), Oak Ridge, Tennessee, United States of America
- Office of Health Equity (OHE), Health Resources and Services Administration (HRSA), Rockville, Maryland, United States of America
| | - Ashley H. Hirai
- Maternal and Child Health Bureau (MCHB), Health Resources and Services Administration (HRSA), Rockville, Maryland, United States of America
| | - Ching-Ching Claire Lin
- Office of Planning, Analysis, and Evaluation (OPAE), Health Resources and Services Administration (HRSA), Rockville, Maryland, United States of America
| | - John E. Snyder
- Office of Planning, Analysis, and Evaluation (OPAE), Health Resources and Services Administration (HRSA), Rockville, Maryland, United States of America
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Sullivan MH, Denslow S, Lorenz K, Dixon S, Kelly E, Foley KA. Exploration of the Effects of Rural Obstetric Unit Closures on Birth Outcomes in North Carolina. J Rural Health 2020; 37:373-384. [PMID: 33289170 DOI: 10.1111/jrh.12546] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Closures of rural labor and delivery (L/D) units have prompted national and state-based efforts to assess the impact on birth outcomes. This study explores local effects of L/D closures in rural areas of North Carolina (NC). METHODS This is a retrospective cohort study of birth outcomes of 4,065 women in 5 rural areas of NC with L/D unit closures between 2013 and 2017. Outcomes were abstracted from birth certificate data from the NC Vital Statistics Reporting System. Localized outcomes 1 year prior to L/D unit closure were compared with outcomes 1 and 2 years post closure, including: (1) birth location and demographics, (2) change in travel patterns for birth, and (3) birth outcomes, including rates of labor induction, cesarean deliveries, maternal morbidity, and neonatal outcomes. FINDINGS Before closures, 25%-56% of deliveries occurred outside county of residence. Commercially insured and college-educated women were more likely to deliver out-of-area. Closures increased travel distance to delivery hospital an average of 7-27 miles. In 2 areas, cesarean delivery rates decreased despite an increase in labor inductions. There was also variability between areas in prenatal care adequacy and breastfeeding. CONCLUSIONS We found that L/D unit closures in rural NC disproportionately affected women on Medicaid. The impact showed area-specific variability, highlighting effects potentially masked by statewide or national analyses. Implications for future L/D closures would be eased by regional coordination and planning to mitigate negative effects, and state and national policies should address the excess burden placed on vulnerable populations.
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Affiliation(s)
- Margaret H Sullivan
- Mission Hospital McDowell, Marion, North Carolina.,Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina
| | - Sheri Denslow
- UNC Health Sciences at Mountain Area Health Education Center, Asheville, North Carolina
| | - Kathleen Lorenz
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina
| | - Suzanne Dixon
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina
| | - Emma Kelly
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Kathleen A Foley
- UNC Health Sciences at Mountain Area Health Education Center, Asheville, North Carolina
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Bailey ZD, Moon JR. Racism and the Political Economy of COVID-19: Will We Continue to Resurrect the Past? JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2020; 45:937-950. [PMID: 32464657 DOI: 10.1215/03616878-8641481] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
COVID-19 is not spreading over a level playing field; structural racism is embedded within the fabric of American culture, infrastructure investments, and public policy and fundamentally drives inequities. The same racism that has driven the systematic dismantling of the American social safety net has also created the policy recipe for American structural vulnerability to the impacts of this and other pandemics. The Bronx provides an important case study for investigating the historical roots of structural inequities showcased by this pandemic; current lived experiences of Bronx residents are rooted in the racialized dismantling of New York City's public infrastructure and systematic disinvestment. The story of the Bronx is repeating itself, only this time with a novel virus. To address the root causes of inequities in cases and deaths due to COVID-19, we need to focus not just on restarting the economy but also on reimagining the economy, divesting of systems rooted in racism, and the devaluation of Black and Brown lives.
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Care for Incarcerated Pregnant People With Opioid Use Disorder: Equity and Justice Implications. Obstet Gynecol 2020; 136:576-581. [PMID: 32769655 DOI: 10.1097/aog.0000000000004002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
With the simultaneous rise in maternal opioid use disorder (OUD) and the incarceration of pregnant people in the United States, we must ensure that prisons and jails adequately address the health and well-being of incarcerated pregnant people with OUD. Despite long-established, clear, and evidence-based recommendations regarding the treatment of OUD during pregnancy, incarcerated pregnant people with OUD do not consistently receive medication treatment and are instead forced into opioid withdrawal. This inadequate care raises multiple concerns, including issues of justice and equity, considerations regarding the legal and ethical obligations of the provision of health care, and violations of the medical and legal rights of incarcerated people. We offer recommendations for improving care for this often-ignored group.
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O'Hanlon CE, Kranz AM, DeYoreo M, Mahmud A, Damberg CL, Timbie J. Access, Quality, And Financial Performance Of Rural Hospitals Following Health System Affiliation. Health Aff (Millwood) 2020; 38:2095-2104. [PMID: 31794306 DOI: 10.1377/hlthaff.2019.00918] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
More than 100 rural hospitals have closed since 2010. Some rural hospitals have affiliated with health systems to improve their financial performance and potentially avoid closure, but the effects of affiliation on rural hospitals and their patients are unclear. To examine the relationship between affiliation and performance, we compared rural hospitals that affiliated with a health system in the period 2008-17 and a propensity score-weighted set of nonaffiliating rural hospitals on twelve measures of structure, utilization, financial performance, and quality. Following health system affiliation, rural hospitals experienced a significant reduction in on-site diagnostic imaging technologies, the availability of obstetric and primary care services, and outpatient nonemergency visits, as well as a significant increase in operating margins (by 1.6-3.6 percentage points from a baseline of -1.6 percent). Changes in patient experience scores, readmissions, and emergency department visits were similar for affiliating and nonaffiliating hospitals. While joining health systems may improve rural hospitals' financial performance, affiliation may reduce access to services for patients in rural areas.
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Affiliation(s)
- Claire E O'Hanlon
- Claire E. O'Hanlon ( cohanlon@rand. org ) is an advanced fellow in health services research in the Center for the Study of Healthcare Innovation, Implementation, and Policy, Veterans Affairs Greater Los Angeles Healthcare System, in California, and an adjunct policy researcher at the RAND Corporation in Santa Monica, California
| | - Ashley M Kranz
- Ashley M. Kranz is a policy researcher at the RAND Corporation in Arlington, Virginia
| | - Maria DeYoreo
- Maria DeYoreo is a statistician at the RAND Corporation in Santa Monica
| | - Ammarah Mahmud
- Ammarah Mahmud is a policy analyst at the RAND Corporation in Arlington
| | - Cheryl L Damberg
- Cheryl L. Damberg is the RAND Distinguished Chair in Healthcare Payment Policy and a principal senior researcher at the RAND Corporation in Santa Monica
| | - Justin Timbie
- Justin Timbie is a senior policy researcher at the RAND Corporation in Arlington
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Dopp A, Zabel Thornton M, Kozhimannil K, Jones CW, Greenfield B. Hospital care for opioid use disorder in pregnancy: Challenges and opportunities identified from a Minnesota survey. ACTA ACUST UNITED AC 2020; 16:1745506520952006. [PMID: 32833589 PMCID: PMC7448132 DOI: 10.1177/1745506520952006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: The prevalence of opioid use disorder continues to rise in the United States, with a simultaneous increase in the diagnosis of both opioid use disorder during pregnancy and neonatal opioid withdrawal syndrome. Despite these increases in pregnancy-related care, little is known about hospital policy and policy implementation related to opioid use disorder in pregnancy. In addition, it is unknown whether policies might differ in rural or urban hospitals. To better examine these issues, Minnesota hospitals were surveyed regarding the existence and implementation of policies related to opioid use disorder in pregnancy and whether any policy implementation challenges had been identified. Methods: From August to December 2017, the research team contacted all Minnesota hospitals that offered obstetric services (n = 82) to survey challenges to implementing policies for opioid use disorder during pregnancy, among other questions. Fifty-nine hospitals had respondents (primarily obstetric department supervisors) who provided information about policy implementation challenges for a 72% response rate. Qualitative responses were analyzed using qualitative description and according to hospital location: metropolitan (urban), micropolitan (rural), or non-core (rural). Results: Ninety-one percent of respondents said that they had pregnancies affected by opioid use disorder at their hospital within the last year. Four major challenges to policy implementation were identified in qualitative responses: (1) provider consensus, (2) patient response to policy, (3) lack of resources, and (4) low frequency of occurrence. All four challenges were more frequently identified by respondents at rural hospitals compared to urban hospitals. Conclusion: This study identified challenges in standardizing hospital care for pregnancies affected by opioid use disorder, and these challenges were identified more frequently in rural locations. These non-urban hospitals may require increased state and federal support and funding.
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Affiliation(s)
- Alana Dopp
- Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School, Duluth, MN, USA
| | - Morgan Zabel Thornton
- Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School, Duluth, MN, USA
| | - Katy Kozhimannil
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Cresta W Jones
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Brenna Greenfield
- Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School, Duluth, MN, USA
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Waits JB, Smith L, Hurst D. Effect of Access to Obstetrical Care in Rural Alabama on Perinatal, Neonatal, and Infant Outcomes: 2003-2017. Ann Fam Med 2020; 18:446-451. [PMID: 32928761 PMCID: PMC7489970 DOI: 10.1370/afm.2580] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/27/2020] [Accepted: 03/10/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To evaluate differential mortality outcomes in rural Alabama counties with or without access to a local labor and delivery (L&D) unit. METHODS This retrospective cohort study used county-level data from the Alabama Department of Public Health. Rural counties in Alabama were categorized into those with an L&D unit and those without. The 2 groups were compared based on infant mortality rate, perinatal mortality rate, neonatal mortality rate, and low birth weight. RESULTS The infant mortality rate from 2003-2017 in the rural counties in Alabama with no local obstetrical care was 9.23 per 1,000 live births, whereas the infant mortality rate during the same period in the rural counties with continuous access to local obstetrical units was 7.89 (relative risk [RR] = 1.1679; 95% CI, 1.0643-1.2817, P = 0.0011). The percentage of low birth weight babies from the time period 2003-2014 in the rural counties in Alabama with no local obstetrical care was 10.61%, compared with 9.86% in the rural counties with continuous access to local L&D services (RR = 1.0756; 95% CI, 1.0424-1.1098, P <.0001). The perinatal mortality rate in counties with no active L&D was 10.82 per 1,000 still + live births compared with 8.89 in counties with an active L&D (RR = 1.2149; 95% CI, 1.1147-1.3242; P <.0001). The neonatal mortality rate during this period was 5.67 per 1,000 live births in counties with no active L&D, vs 4.74 in those counties with L&D services (RR = 1.1953; 95% CI, 1.0609-1.3466; P = 0.0034). CONCLUSION Access to local obstetrical care in a rural area is associated with better infant outcomes.
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Affiliation(s)
| | - Lacy Smith
- Cahaba Medical Care, Centreville, Alabama
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Barreto TW, Estacio A, Winkler P. The Overlap Between Rural Hospital Needs and Medical Student Goals in Texas. PRIMER (LEAWOOD, KAN.) 2020; 4:18. [PMID: 33111045 PMCID: PMC7581194 DOI: 10.22454/primer.2020.808983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION The rural health workforce in the United States is difficult to maintain and harder to increase. This may contribute to worse health outcomes in rural areas and threaten the sustainability of rural hospitals. Previous studies have attempted to identify medical student characteristics and strategies to help grow this workforce. In this study, we aimed to understand the needs of medical students and hospital administrators to identify potential strategies to improve the rural health workforce. METHODS We conducted medical student and hospital administrator focus groups. We analyzed focus group data separately to identify themes, and reviewed these themes for overlap between groups and potential actionable areas. We calculated Cohen κ statistics. RESULTS We identified 26 themes in the medical student focus groups, and 14 themes in the hospital administrator focus group. Of these themes, three were identical between groups (scope of practice, loan repayment and financial concerns, and exposure to rural health in training), and two were similar between the groups (family and leadership). CONCLUSION The identification of two themes that are similar but not identical between medical students and hospital administrators may serve as part of future strategies to improving rural physician recruitment. Future studies should determine if a shift in language or focus in these areas specifically help to improve the rural health workforce.
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Affiliation(s)
- Tyler W Barreto
- Sea Mar Marysville Family Medicine Residency, Marysville, WA
| | - Alvin Estacio
- South Central Area Health Education Center, San Antonio, TX
| | - Paula Winkler
- South Central Area Health Education Center, San Antonio, TX
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Kozhimannil KB, Interrante JD, Tuttle MS, Henning-Smith C, Admon L. Characteristics of US Rural Hospitals by Obstetric Service Availability, 2017. Am J Public Health 2020; 110:1315-1317. [PMID: 32673119 DOI: 10.2105/ajph.2020.305695] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Katy B Kozhimannil
- Katy B. Kozhimannil, Julia D. Interrante, Mariana S. Tuttle, and Carrie Henning-Smith are with the University of Minnesota Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis. Lindsay Admon is with the Department of Obstetrics and Gynecology and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Julia D Interrante
- Katy B. Kozhimannil, Julia D. Interrante, Mariana S. Tuttle, and Carrie Henning-Smith are with the University of Minnesota Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis. Lindsay Admon is with the Department of Obstetrics and Gynecology and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Mariana S Tuttle
- Katy B. Kozhimannil, Julia D. Interrante, Mariana S. Tuttle, and Carrie Henning-Smith are with the University of Minnesota Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis. Lindsay Admon is with the Department of Obstetrics and Gynecology and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Carrie Henning-Smith
- Katy B. Kozhimannil, Julia D. Interrante, Mariana S. Tuttle, and Carrie Henning-Smith are with the University of Minnesota Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis. Lindsay Admon is with the Department of Obstetrics and Gynecology and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Lindsay Admon
- Katy B. Kozhimannil, Julia D. Interrante, Mariana S. Tuttle, and Carrie Henning-Smith are with the University of Minnesota Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis. Lindsay Admon is with the Department of Obstetrics and Gynecology and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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Kozhimannil KB, Interrante JD, Tuttle MKS, Henning-Smith C. Changes in Hospital-Based Obstetric Services in Rural US Counties, 2014-2018. JAMA 2020; 324:197-199. [PMID: 32662854 PMCID: PMC7361647 DOI: 10.1001/jama.2020.5662] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study describes hospital-based obstetric service losses in rural US counties between 2014 and 2018 overall and by county population and urban adjacency.
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Affiliation(s)
- Katy B. Kozhimannil
- University of Minnesota Rural Health Research Center, University of Minnesota School of Public Health, Minneapolis
| | - Julia D. Interrante
- University of Minnesota Rural Health Research Center, University of Minnesota School of Public Health, Minneapolis
| | - Mariana K. S. Tuttle
- University of Minnesota Rural Health Research Center, University of Minnesota School of Public Health, Minneapolis
| | - Carrie Henning-Smith
- University of Minnesota Rural Health Research Center, University of Minnesota School of Public Health, Minneapolis
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