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

Impact of post-Dobbs abortion restrictions on maternal-fetal medicine physicians in the Southeast: a qualitative study

BACKGROUND

The United States Supreme Court overturned federal abortion protections in Dobbs v Jackson Women's Health Organization. Many states in the Southeastern United States responded with restrictive policies that limit and criminalize abortion care.

OBJECTIVE

This study aimed to characterize the effect of abortion restrictions on maternal-fetal medicine physicians in the Southeastern United States after the Dobbs decision.

STUDY DESIGN

Qualitative, semistructured interviews with 35 maternal-fetal medicine physicians in 10 Southeastern states between February 2023 and June 2023 were conducted. Our recruitment strategy relied on convenience and snowball sampling. Audio-recorded interviews were analyzed using Dedoose software and a descriptive qualitative approach that incorporated deductive and inductive approaches.

RESULTS

Emergent themes were identified, and a conceptual framework was developed on the basis of overarching themes. This study found that abortion laws and external constraints after the Dobbs decision resulted in ethical, professional, and legal challenges for maternal-fetal medicine physicians that led to changes in clinical practice and deviations from patient-centered care. These forced changes resulted in negative effects on maternal-fetal medicine physicians, such as increased fear, hypervigilance, and increased workload. In addition, these changes prompted concerns about health risks and negative emotional effects for patients. Supportive colleagues, hospital systems, and policies were associated with decreased stress, emotional distress, and disruption of healthcare delivery.

CONCLUSION

Abortion restrictions in the Southeastern United States limit the ability of maternal-fetal medicine physicians to provide or facilitate abortions in the setting of fetal anomalies and maternal health risks. Maternal-fetal medicine physicians perceived these restrictions to have negative professional and emotional repercussions for themselves and negative effects on patients. Supportive colleagues and clear guidance from hospital systems and departments on how to interpret the laws were protective. Our findings have implications for the maternal-fetal medicine workforce and patient care in the region.

Regional Differences in the US in Outcomes with Preeclampsia

This study explores preeclampsia outcomes across US regions and examines regional differences in specific preeclampsia-associated pregnancy complications and disease management. Patient-reported measures were obtained from The Preeclampsia Registry, an open-access database composed of women with at least one pregnancy diagnosed with a hypertensive disorder of pregnancy. Pregnancies and associated outcomes were stratified by US region (Northeast, Midwest, South and West). Among 2,667 pregnancies of which 92% were in White women, maximum systolic blood pressure at any time in pregnancy was highest among women in the South and Midwest (p=0.039). Furthermore, more women in the South received pre-pregnancy antihypertensives (p=0.026) and antenatal steroids (p=0.025) and delivered at an earlier gestational age (p=0.014) compared to women in other regions. Pregnancy complications such as elevated liver enzymes were higher in women in the South (p=0.019), and women in the South and West had additional end-organ damage such as renal complications (p<0.001) and hemolysis (p=0.008) as compared to women in other regions. Further investigation is needed to assess whether healthcare access or policy could be contributing to these regional discrepancies.

Risk Factors for Severe Maternal Morbidity Among Women Enrolled in Mississippi Medicaid

Importance

Mississippi has one of the highest rates of severe maternal morbidity (SMM) in the US, and SMMs have been reported to be more frequent among Medicaid-insured women. A substantial proportion of pregnant women in Mississippi are covered by Medicaid; hence, there is a need to identify potential risk factors for SMM in this population.

Objective

To examine the associations of health care access and clinical and sociodemographic characteristics with SMM events among Mississippi Medicaid-enrolled women who had a live birth.

Design, Setting, and Participants

A nested case-control study was conducted using 2018 to 2021 Mississippi Medicaid administrative claims database. The study included Medicaid beneficiaries aged 12 to 55 years who had a live birth and were continuously enrolled throughout their pregnancy period and 12 months after delivery. Individuals in the case group had SMM events and were matched to controls on their delivery date using incidence density sampling. Data analysis was performed from June to September 2022.

Exposure

Risk factors examined in the study included sociodemographic factors (age and race), health care access (distance from delivery center, social vulnerability index, and level of maternity care), and clinical factors (maternal comorbidity index, first-trimester pregnancy-related visits, and postpartum care).

Main Outcomes and Measures

The main outcome of the study was an SMM event. Adjusted odds ratio (aORs) and 95% CIs were calculated using conditional logistic regression.

Results

Among 13 485 Mississippi Medicaid-enrolled women (mean [SD] age, 25.0 [5.6] years; 8601 [63.8%] Black; 4419 [32.8%] White; 465 [3.4%] other race [American Indian, Asian, Hispanic, multiracial, and unknown]) who had a live birth, 410 (3.0%) were in the case group (mean [SD] age, 26.8 [6.4] years; 289 [70.5%] Black; 112 [27.3%] White; 9 [2.2%] other race) and 820 were in the matched control group (mean [SD] age, 24.9 [5.7] years; 518 [63.2%] Black; 282 [34.4%] White; 20 [2.4%] other race). Black individuals (aOR, 1.44; 95% CI, 1.08-1.93) and those with higher maternal comorbidity index (aOR, 1.27; 95% CI, 1.16-1.40) had higher odds of experiencing SMM compared with White individuals and those with lower maternal comorbidity index, respectively. Likewise, an increase of 100 miles (160 km) in distance between beneficiaries' residence to the delivery center was associated with higher odds of experiencing SMM (aOR, 1.14; 95% CI, 1.07-1.20).

Conclusions and Relevance

The study findings hold substantial implications for identifying high-risk individuals within Medicaid programs and call for the development of targeted multicomponent, multilevel interventions for improving maternal health outcomes in this highly vulnerable population.

Skin-To-Skin Contact During Cesarean Birth in the United States over the Last Decade

PURPOSE

To assess skin-to-skin contact during cesarean birth, including incidence and maternal characteristics.

STUDY DESIGN AND METHODS

A cross-sectional, retrospective study using survey methods was conducted. Women who had a cesarean birth within the last 10 years prior to January 2022 were recruited via social media. Descriptive statistics, chi square, and binary logistic regression analyses were calculated.

RESULTS

There were 2,327 participants, of which 29.7% experienced skin-to-skin contact during their cesarean birth. This was reported to be less often than desired. Significant associations were found among skin-to-skin contact during cesarean birth and planned cesarean birth, previous cesarean birth, maternal age, level of education, and birth region. Previous vaginal birth and race were not significantly associated with skin-to-skin contact during cesarean birth. Most (93.65%) respondents identified as White. Barriers to skin-to-skin contact during cesarean birth may be birth region, unplanned or emergency cesarean births, younger age, lacking a college degree, and lack of previous cesarean births.

CLINICAL IMPLICATIONS

There are differences in incidence and access to skin-to-skin contact during cesarean birth. Our findings emphasize the continued need to address disparities in care, increase maternal health care equity, and make skin-to-skin contact during cesarean birth available for all women who desire it.

Evaluation of a method to identify midwives in national provider identifier data

OBJECTIVES

Comparison of national midwife workforce data from the National Provider Identifier file determined it undercounted midwives compared to national data available from the American Midwifery Certification Board. This undercount may be due to the existence of three taxonomy categories for midwives when registering for the National Provider Identifier. The objective of this study was to obtain an accurate count of advanced practice midwives using the National Provider Identifier Data.

METHODS

A recode strategy was created using the NPPES Data Dissemination File for November 7, 2021. The strategy identified advanced practice midwives using education and certification information provided in the "credentials" field. The strategy was validated using the NPPES Data Dissemination File for August 7, 2022 and the gold standard was the American Midwifery Certification Board count of midwives by state for August, 2022. Validation compared the accuracy and precision of the recode to the accuracy and precision of using the advanced practice midwife taxonomy category.

RESULTS

The recode strategy improved the accuracy and precision of the count of advanced practice midwives compared to the identification of advanced practice midwives using the advanced practice midwife taxonomy category.

CONCLUSIONS FOR PRACTICE

Recoding the NPPES Data Dissemination File provides a more accurate and precise count of advanced practice midwives than relying on the existing advanced practice midwife taxonomy classification. Researchers can use the NPPES Data Dissemination File when studying the midwifery workforce.

Contribution of Health Care Practitioner and Maternity Services Factors to Racial Disparities in Alabama: A Qualitative Study

OBJECTIVE

Black patients are three times more likely to die of pregnancy-related causes than White patients in the United States, and Alabama has the third worst maternal mortality rate in the nation. We sought to identify health care practitioner and maternity service factors contributing to disparities in Alabama, as well as potential strategies to address these contributors.

METHODS

We conducted key informant interviews with obstetricians, nurses, doulas, lactation counselors, health system administrators, and representatives of professional organizations who deliver maternity care to racially and ethnically diverse patients in Alabama. The interview guide was developed using Howell's conceptual framework on racial and ethnic disparities in severe maternal morbidity and mortality. Adopting a thematic analysis approach, we coded and analyzed transcripts using NVivo 12 software. Open coding and selective coding were conducted to identify themes related to health care practitioner- and maternity services-level determinants.

RESULTS

Overall, 20 health care practitioners or administrators were interviewed. Primary themes related to health care practitioners included implicit bias and explicit racism, lack of communication and lack of positive patient-health care practitioner relationships, lack of cultural sensitivity, and variation in clinical knowledge and experience. Primary themes related to maternity services included lack of accessibility, inadequate quality and content of care, lack of continuity of care, discriminatory facility policies, and workforce shortages and lack of diversity. Strategies suggested by participants to address these factors included bias trainings for health care practitioners, improvements in racial and interdisciplinary diversity in the maternity workforce, and evidence-based interventions such as group prenatal care, disparities dashboards, simulation trainings, early warning signs criteria, and coordinated care.

CONCLUSION

We gained diverse perspectives from health care practitioners and administrators on how maternity health care practitioner and maternity health services factors contribute to inequities in maternal health in Alabama. Strategies to address these contributing factors were multifaceted.

Training in Residency and Provision of Reproductive Health Services Among Family Medicine Physicians

Importance

Contraception and abortion services are essential health care, and family medicine (FM) physicians are an important part of the workforce providing this care. Residency could inform the reproductive health services FM physicians provide.

Objective

To determine which residency training factors are associated with FM physicians' provision of reproductive health services to Medicaid beneficiaries.

Design, Setting, and Participants

This cross-sectional, population-based observational study of inpatient and outpatient FM physicians who completed residency between 2008 and 2018 and treated at least 1 Medicaid beneficiary in 2019 was conducted from November 2022 to March 2023. The study used 2019 American Medical Association Masterfile and Historical Residency file, as well as the 2019 Transformed Medicaid Statistical Information System claims.

Exposures

Residency training in community-based or reproductive health-focused programs.

Main Outcomes and Measures

The outcomes were providing the following to at least 1 Medicaid beneficiary in 2019: prescription contraception (pill, patch, and/or ring), intrauterine device (IUD) and/or contraceptive implant, and dilation and curettage (D&C). Odds of providing each outcome were measured using correlated random-effects regression models adjusted for physician, residency program, and county characteristics.

Results

In the sample of 21 904 FM physician graduates from 410 FM residency programs, 12 307 were female (56.3%). More than half prescribed contraception to Medicaid beneficiaries (13 373 physicians [61.1%]), with lower proportions providing IUD or implant (4059 physicians [18.5%]) and D&C (152 physicians [.7%]). FM physicians who graduated from a Reproductive Health Education in Family Medicine program, which fully integrates family planning into residency training, had significantly greater odds of providing prescription contraception (odds ratio [OR], 1.23; 95% CI, 1.07-1.42), IUD or implant (OR, 1.79; 95% CI, 1.28-2.48), and D&C (OR, 3.61; 95% CI, 2.02-6.44). Physicians who completed residency at a Teaching Health Center, which emphasizes community-based care, had higher odds of providing an IUD or implant (OR, 1.51; 95% CI, 1.19-1.91).

Conclusions and Relevance

In this cross-sectional study of FM physicians providing Medicaid service, characteristics of residency training including community-based care and integration of family planning training are associated with greater odds of providing reproductive health services. With growing reproductive health policy restrictions, providing adequate training in reproductive health is critical to maintaining access to care, especially for underserved populations.

Nursing Resources by Type of Maternity Unit Across Regions of the United States

OBJECTIVE

To examine variation in nursing resources across three different types of maternity units in five regions of the United States.

DESIGN

Cross-sectional descriptive.

SETTING

Maternity units in hospitals in 48 states and the District of Columbia that participated in the 2016 National Database of Nursing Quality Indicator survey.

PARTICIPANTS

Staff nurses (N = 19,486) who worked in 707 maternity units.

METHODS

We conducted a secondary analysis of survey data examining nursing resources (work environment, staffing, education, specialty certification) by type of maternity unit, including labor and delivery, labor/delivery/recovery/postpartum, and postpartum. We used descriptive statistics and analysis of variance.

RESULTS

Participants worked in 707 units (269 labor and delivery units, 164 labor/delivery/recovery/postpartum units, and 274 postpartum units) in 444 hospitals. The work environment was not significantly different across unit types (mean = 2.89-2.94, p = .27). Staffing, education, and specialty certification varied significantly across the unit types (p ≤ .001). In terms of staffing, postpartum units had, on average, almost twice the number of patients per nurse as labor and delivery units (7.51 patients/nurse vs. 4.01 patients/nurse, p ≤ .001) and 1.5 times more patients than labor/delivery/recovery/postpartum units (5.04 patients/nurse vs. 4.01 patients/nurse, p ≤ .001).

CONCLUSION

Nursing resources varied significantly across types of maternity units and regions of the United States. This variation suggests that improving nursing resources may be a system-level target for improving maternity care in the United States.

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

Background: To investigate rural-urban differences in hospital-based care utilization among women of reproductive age (18-44 years). Methods: Rural-urban differences were estimated for hospital outpatient visits, emergency department (ED) visits, hospitalizations, and associated expenditures both overall and by insurance status, by analyzing a nationally representative sample of women of reproductive age from the Medical Expenditure Panel Survey (2006-2015). Results: The study sample consisted of 48,114 women of reproductive age. Unadjusted results showed that rural women reported higher likelihood of hospital outpatient visits (rural vs. urban: 17.10% vs. 13.34%) although, among those using such care, fewer average visits (rural vs. urban: 2.00 vs. 2.56 visits). Rural women reported higher likelihood of ED visits (rural vs. urban: 18.13% vs. 15.11%) and more hospital stays (rural vs. urban: 0.13 vs. 0.11 stays). Adjusted results showed rural women had higher likelihood of outpatient care use (+2.5 percentage points; 95% confidence interval [CI] = 0.002-0.049) but fewer visits (-0.314 visits, 95% CI = -0.566 to -0.062). For the privately insured, rural women had greater likelihood of outpatient care (+3.1 percentage points, 95% CI = 0.001-0.060) and fewer ED visits (-0.031 visits, 95% CI = -0.061 to -0.003); for the publicly insured, rural women had more hospital stays (+0.045 stays, 95% CI = 0.009-0.083); for the uninsured, rural women had fewer outpatient visits among those using such care (-1.118 visits, 95% CI = -1.865 to -0.372) and shorter hospital stays overall (-0.093 nights, 95% CI = -0.181 to -0.005). Rural-urban expenditure differences were not significant between any insurance grouping. Conclusions: Rural-urban differences in hospital-based care utilization were observed, although somewhat heterogeneous by insurance status. Strengthening outpatient and preventive service access, particularly for publicly insured and uninsured rural women of reproductive age, is important for shifting care to lower cost settings and improving population health.

From convergence to divergence: Lifespan variation in US states, 1959-2017

BACKGROUND

Large disparities in life expectancy exist across US states and the gaps have been widening in recent decades. Less is known about the lifespan variability - a measure that can provide important insights into mortality inequalities both between and within states.

METHOD

Using yearly lifetables from the United States Mortality Database, we explore geographic and temporal patterns in lifespan variation (unconditional and conditional on survival to age 10, 35 and 65) across US states between 1959 and 2017. We also examine the contribution of state differences in life expectancy to overall lifespan variation using standard decomposition techniques.

RESULTS

Despite overall convergence in lifespan variation across states over the last six decades, in more recent years there has been notable divergence. Gender-specific analyses show that lifespan variation was generally greater among males than among females; but this pattern reverses for mortality past age 65. Much of the state disparities in lifespan variation, unconditional and conditional on survival to age 10 and 35, were due to mortality differences under the age 65. Decomposition analysis shows that while within-state variability remains the primary driver of overall lifespan variation, the contribution of cross-state differences in life expectancy is growing.

CONCLUSIONS

Variation in longevity is greater within US States than between them, yet cross-states disparities in mortality are increasing. This likely reflects the long-term consequences of rising social, economic, and political stratification for health inequalities both within and across states.

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

BACKGROUND

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

METHODS AND FINDINGS

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

CONCLUSION

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