Health care use and health consequences of geographic lack of access to abortion and maternity care

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.

Association of Food Desert Residency and Preterm Birth in the United States

INTRODUCTION

Food deserts are a major public health concern. Inadequate access to healthy food has been associated with poor nutrition and the development of dietary related chronic conditions.

OBJECTIVE

To determine the association between geographic access to nutritious food and preterm birth and whether gestational hypertension mediates this relationship.

METHODS

Food access data was retrieved from the U.S. Department of Agriculture Food Access Research Atlas (2019) and used to quantify the percentage of Census tracts within each county that were food deserts: low-income tracts with limited access to grocery stores, supermarkets, or other sources of healthy, nutritious foods. These data were merged with US birth records from 2018 to 2019 by using the maternal county of residence (n = 7,533,319). We fit crude and adjusted logistic regression models with generalized estimating equations to determine the association between living in a food desert and the odds of preterm birth. We conducted a secondary within-group analysis by stratifying the fully adjusted model by race for non-Hispanic White and non-Hispanic Black birthing people.

RESULTS

In the fully adjusted model, we found a dose-response relationship. As the prevalence of tract-level food deserts within counties increased, so did the likelihood of preterm birth (mid-range: odds ratio (OR) = 1.04, 95% confidence interval (C.I.) 1.01-1.07; high: OR = 1.07, 95% C.I. 1.03-1.11). Similar results were seen in the White-Black stratified models. However, a disparity remained as Black birthing people had the highest odds for preterm birth. Lastly, gestational hypertension appears to mediate the relationship between nutritious food access and preterm birth (natural indirect effect (NIE) = 1.01, 95% CI = 1.00, 1.01).

CONCLUSION

It is salient, particularly for Black birthing people who experience high rates of adverse birth outcomes, that the role of food desert residency be explored within maternal and child health disparities.

Maternity Care Deserts in Louisiana and Breastfeeding Initiation

BACKGROUND

Breastfeeding provides physical, psychological, and immunological benefits to both the mother and infant, but breastfeeding rates are suboptimal. The purpose of this study was to examine whether residing in a maternity care desert (a county with no hospital offering obstetric care and no OB/GYN or certified nurse midwife providers) was associated with lower breastfeeding rates among birthing people in Louisiana from 2019 to 2020.

METHODS

Data provided by the March of Dimes were used to classify Louisiana parishes by level of access to maternity care. Using data on all live births provided by the Louisiana Office of Vital Records (n = 112,151), we fit adjusted modified Poisson regression models with generalized estimating equations and exploratory geospatial analysis to examine the association between place of residence and breastfeeding initiation and racial disparities in initiation. We conducted a secondary within-group analysis by fitting the fully adjusted model stratified by race/ethnicity for non-Hispanic white and non-Hispanic Black birthing people.

RESULTS

We found that residing in a parish with limited (odds ratio [OR] = 0.87; 95% confidence interval [CI] [0.77, 0.99]) to no access (OR = 0.88; 95% CI [0.80, 0.97]) was significantly associated with lower breastfeeding initiation rates. The within-group analysis determined that both non-Hispanic Black and non-Hispanic white birthing people residing in a parish with limited or no maternity care access had lower breastfeeding initiation rates.

CONCLUSION

Reducing rural and racial inequities in breastfeeding may require structural changes and investments in infrastructure to deliver pregnancy care.

US county-level prevalence and spatial distribution of optimal birth outcomes 2018-2019

A shift in focus towards healthy reproductive outcomes may reveal opportunities for novel interventions and strategies to promote optimal health. Using variables from the National Center for Health Statistics restricted use natality files, we calculated Empirical Bayes smoothed (EBS) rates of optimal birth for the all live births-both overall and by maternal race/ethnicity-by applying the smoothing tool in GeoDa version 1.18.0.10 We defined counties achieving greater racial birth equity as those where the overall EBS optimal birth rate was greater than the national 75th percentile and the absolute difference between maternal racial/ethnic categories was smaller than the national 25th percentile difference. During the study period, 49.80% of overall births could be classified as an optimal birth according to the study definition. Of the 3140 US counties, only 282 (8.98%) appeared to advance White-Black equity in optimal births, and 205 (6.53%) appeared to advance White-Hispanic equity in optimal births. In the effort improve maternal health, we should focus not only on the absence of negative outcomes, but also the occurrence of positive outcomes. Our analytic results suggest that optimal births can be measured and that geographic inequities by race occur.

Income Inequality and Pregnancy-Associated Homicide in the US: A Longitudinal, State-Level Analysis

Pregnancy-associated homicide remains an understudied yet critical issue. Using restricted use mortality files provided by the National Center for Health Statistics and the National Violent Death Reporting System, annual state-level pregnancy-associated homicide ratios were estimated as the count of deaths divided by the number of live births. The exposure, the state Gini index, was categorized into tertiles to compare states by levels of income inequality. In the final adjusted longitudinal linear model, those who experienced the greatest amount of income inequality had a significant 1.28 per 100,000 homicide rate when compared to the lowest income inequality tertile.

The Index of Concentration at the Extremes (ICE) and Pregnancy-Associated Mortality in Louisiana, 2016-2017

OBJECTIVES

Social and contextual factors underlying the continually disproportionate and burdensome risk of adverse health outcomes experienced by Black women in the US are underexplored in the literature. The aim of this study was to use an index based on area-level population distributions of race and income to predict risk of death during pregnancy and up to 1 year postpartum among women in Louisiana.

METHODS

Using vital records data provided by the Louisiana Department of Health 2016-2017 (n = 125,537), a modified Poisson model was fit with generalized estimating equations to examine the risk of pregnancy-associated death associated with census tract-level values of the Index of Concentration at the Extremes (ICE)-grouped by tertile-while adjusting for both individual and tract-level confounders.

RESULTS

Analyses resulted in an estimated 1.73 (95% CI 1.02-2.93) times increased risk for pregnancy-associated death for those in areas which were characterized by concentrated deprivation (high proportions of Black and low-income residents) relative to those in areas of concentrated privilege (high proportions of white and high-income residents), independent of other factors.

CONCLUSIONS FOR PRACTICE

In addition to continuing to consider the deeply entrenched racism and economic inequality that shape the experience of pregnancy-associated death, we must also consider their synergistic effect on access to resources, maternal population health, and health inequities.

Advanced Trauma Life Support Course Delivery: Comparison of Outcomes From Modifications During Covid-19

Introduction The Advanced Trauma Life Support (ATLS) Course is a two-day long medical training course developed by the American College of Surgeons (ACS) to help train and prepare healthcare providers to care for severely injured patients. The coronavirus disease 2019 (COVID-19) pandemic has resulted in the modification or cancellation of many education programs across the world. At the University of South Florida's Center for Advanced Medical Learning and Simulation (CAMLS) two different models of ATLS were delivered in response to the COVID-19 pandemic with both models utilizing the ACS's online mobile ATLS (mATLS). In this study three different models of ATLS delivered by USF CAMLS between 2019 and 2020 were compared to determine if there were any impacts on the education and functionality of the ATLS course between the three different models of ATLS: a baseline ATLS course, an augmented ATLS course that used mATLS, and an ATLS course that used mATLS as a replacement for in-person lectures. Material and methods To compare the three models of ATLS delivery, a total of six ATLS courses were studied: a baseline face-to-face ATLS course from June 2019, two Mobile ATLS (mATLS) courses from September 2020, and three augmented ATLS courses that contained both face-to-face and mATLS delivery from October, November and December 2020. The only differences between the traditional ATLS courses from 2020 and the pre-COVID ATLS course from 2019 were that the courses from 2020 utilized mATLS and that the course days were longer due to cleaning time. These courses were selected to have a non-significant difference in the number of learners in each model of ATLS course. The data that were collected from these courses included: post-test results from learners, learner feedback surveys, and interviews with the ATLS Course Director, ATLS Course Coordinator, and the Educational Coordinator. Results The only courses with significant differences in the post-test mean scores were for the baseline ATLS course compared to the mATLS courses. The augmented courses showed similar post-test performance to the mATLS courses. Students viewed the courses favorably with the only major complaint between the 2019 and the 2020 courses being a high amount of downtime for the 2020 courses due to time required to disinfect skill stations and equipment. The main difficulties for the ATLS Course Director, ATLS Course Coordinator, and the Educational Coordinator with the ATLS courses in 2020 were concerned with challenges from COVID-19, like social distancing, and not with mATLS or the shortened instruction time with the hybrid model. Discussion This preliminary study analyzed three delivery models of ATLS. The mATLS may be able to replace in-person lectures of ATLS courses as courses using alternative delivery formats showed post-test scores as good or better than the baseline face-to-face course.

Structural racism, racial inequities and urban-rural differences in infant mortality in the US

Background

While evidence shows considerable geographic variations in county-level racial inequities in infant mortality, the role of structural racism across urban–rural lines remains unexplored. The objective of this study was to examine the associations between county-level structural racism (racial inequity in educational attainment, median household income and jail incarceration) and infant mortality and heterogeneity between urban and rural areas.

Methods

Using linked live birth/infant death data provided by the National Center for Health Statistics, we calculated overall and race-specific 2013–2017 5-year infant mortality rates (IMRs) per 1000 live births in every county. Racially stratified and area-stratified negative binomial regression models estimated IMR ratios and 95% CIs associated with structural racism indicators, adjusting for county-level confounders. Adjusted linear regression models estimated associations between structural racism indicators and the absolute and relative racial inequity in IMR.

Results

In urban counties, structural racism indicators were associated with 7%–8% higher black IMR, and an overall structural racism score was associated with 9% greater black IMR; however, these findings became insignificant when adjusting for the region. In white population, structural racism indicators and the overall structural racism score were associated with a 6% decrease in urban white IMR. Both absolute and relative racial inequity in IMR were exacerbated in urban counties with greater levels of structural racism.

Conclusions

Our findings highlight the complex relationship between structural racism and population health across urban–rural lines and suggest its contribution to the maintenance of health inequities in urban settings.

Mass incarceration and public health: the association between black jail incarceration and adverse birth outcomes among black women in Louisiana

BACKGROUND

A growing body of evidence is beginning to highlight how mass incarceration shapes inequalities in population health. Non-Hispanic blacks are disproportionately affected by incarceration and criminal law enforcement, an enduring legacy of a racially-biased criminal justice system with broad health implications for black families and communities. Louisiana has consistently maintained one of the highest rates of black incarceration in the nation. Concurrently, large racial disparities in population health persist.

METHODS

We conducted a cross-sectional analysis of all births among non-Hispanic black women in Louisiana in 2014 to identify associations between parish-level (county equivalent) prevalence of jail incarceration within the black population and adverse birth outcomes (N = 23,954). We fit a log-Poisson model with generalized estimating equations to approximate the relative risk of preterm birth and low birth weight associated with an interquartile range increase in incarceration, controlling for confounders. In sensitivity analyses, we additionally adjusted for the parish-level index crime prevalence and analyzed regression models wherein white incarceration was used to predict the risk of adverse birth outcomes in order to quantify the degree to which mass incarceration may harm health above and beyond living in a high crime area.

RESULTS

There was a significant 3% higher risk of preterm birth among black women associated with an interquartile range increase in the parish-level incarceration prevalence of black individuals, independent of other factors. Adjusting for the prevalence of index crimes did not substantively change the results of the models.

CONCLUSION

Due to the positive significant associations between the prevalence of black individuals incarcerated in Louisiana jails and estimated risk of preterm birth, mass incarceration may be an underlying cause of the persistent inequities in reproductive health outcomes experienced by black women in Louisiana. Not only are there economic and social impacts stemming from mass incarceration, but there may also be implications for population health and health inequities, including the persistence of racial disparities in preterm birth and low birth weight.

Spinal cord motor neuron plasticity accompanies second-degree burn injury and chronic pain

Burn injuries and associated complications present a major public health challenge. Many burn patients develop clinically intractable complications, including pain and other sensory disorders. Recent evidence has shown that dendritic spine neuropathology in spinal cord sensory and motor neurons accompanies central nervous system (CNS) or peripheral nervous system (PNS) trauma and disease. However, no research has investigated similar dendritic spine neuropathologies following a cutaneous thermal burn injury. In this retrospective investigation, we analyzed dendritic spine morphology and localization in alpha-motor neurons innervating a burn-injured area of the body (hind paw). To identify a molecular regulator of these dendritic spine changes, we further profiled motor neuron dendritic spines in adult mice treated with romidepsin, a clinically approved Pak1-inhibitor, or vehicle control at two postburn time points: Day 6 immediately after treatment, or Day 10 following drug withdrawal. In control treated mice, we observed an overall increase in dendritic spine density, including structurally mature spines with mushroom-shaped morphology. Pak1-inhibitor treatment reduced injury-induced changes to similar levels observed in animals without burn injury. The effectiveness of the Pak1-inhibitor was durable, since normalized dendritic spine profiles remained as long as 4 days despite drug withdrawal. This study is the first report of evidence demonstrating that a second-degree burn injury significantly affects motor neuron structure within the spinal cord. Furthermore, our results support the opportunity to study dendritic spine dysgenesis as a novel avenue to clarify the complexities of neurological disease following traumatic injury.

Income inequality and racial disparities in pregnancy-related mortality in the US

In this ecological study, we examined the associations between state-level income inequality and pregnancy-related mortality among non-Hispanic (NH) black and NH white populations across the US. We estimated total population and race-specific 5-year pregnancy-related mortality ratios in each state based on national death and live birth records from 2011 to 2015. We obtained data on Gini coefficients for income inequality and population-level characteristics from the US Census American Community Survey. Poisson regression with robust standard errors estimated pregnancy-related mortality rate ratios (RR) and 95% confidence intervals (CI) associated with a one unit increase in income inequality overall and separately within black and white populations. Adjusted linear regression models estimated the associations between income inequality and magnitude of the absolute and relative racial inequity in pregnancy-related mortality within states. Across all states, increasing contemporaneous income inequality was associated with a 15% and 5-year lagged inequality with 14% increase in pregnancy-related mortality among black women (aRR = 1.15, 95% CI = 1.05; 1.25 and aRR = 1.14, 95% CI = 1.04; 1.24, respectively) after controlling for states' racial compositions and socio-economic conditions. In addition, both lagged and contemporaneous income inequality were associated with larger absolute and relative racial inequities in pregnancy-related mortality. These findings highlight the role of contextual factors in contributing to pregnancy-related mortality among black women and the persistent racial inequity in maternal death in the US.

Biotic, temporal and spatial variability of tritium concentrations in transpirate samples collected in the vicinity of a near-surface low-level nuclear waste disposal site and nearby research reactor

The results of a 21 month sampling program measuring tritium in tree transpirate with respect to local sources are reported. The aim was to assess the potential of tree transpirate to indicate the presence of sub-surface seepage plumes. Transpirate gathered from trees near low-level nuclear waste disposal trenches contained activity concentrations of (3)H that were significantly higher (up to ∼700 Bq L(-1)) than local background levels (0-10 Bq L(-1)). The effects of the waste source declined rapidly with distance to be at background levels within 10s of metres. A research reactor 1.6 km south of the site contributed significant (p < 0.01) local fallout (3)H but its influence did not reach as far as the disposal trenches. The elevated (3)H levels in transpirate were, however, substantially lower than groundwater concentrations measured across the site (ranging from 0 to 91% with a median of 2%). Temporal patterns of tree transpirate (3)H, together with local meteorological observations, indicate that soil water within the active root zones comprised a mixture of seepage and rainfall infiltration. The degree of mixing was variable given that the soil water activity concentrations were heterogeneous at a scale equivalent to the effective rooting volume of the trees. In addition, water taken up by roots was not well mixed within the trees. Based on correlation modelling, net rainfall less evaporation (a surrogate for infiltration) over a period of from 2 to 3 weeks prior to sampling seems to be the optimum predictor of transpirate (3)H variability for any sampled tree at this site. The results demonstrate successful use of (3)H in transpirate from trees to indicate the presence and general extent of sub-surface contamination at a low-level nuclear waste site.