Introduction: The objectives of this study were to include readmissions and physician costs in the estimates of total costs of severe maternal morbidity (SMM), to consider the effect of SMM on maternal length of stay (LOS), and to examine these for the more restricted definition of SMM that excludes transfusion-only cases. Methods: California linked birth certificate-patient discharge data for 2009 through 2011 (n = 1,262,862) with complete costs and LOS were used in a secondary data analysis. Cost-to-charge ratios were used to estimate costs from charges, adjusting for inflation. Physician payments were estimated from the mean payments for specific diagnosis-related groups. Generalized linear models estimated the association between SMM and costs and LOS. Results: Excluding readmissions and physician costs, SMM was associated with a 60% increase in hospital costs (marginal effect [ME], $3,550) and a 33% increase in LOS (ME 0.9 days). These increased to 70% (ME $5,806) and 46% (ME 1.3 days) when physician costs and readmissions were included. The effects of SMM were roughly one-half as large for patients who only required a blood transfusion (49% [ME $4,056] and 31% [ME 0.9 days]) as for patients who had another indicator for SMM (93% [ME $7,664] and 62% [ME 1.7 days]). Conclusions: Postpartum hospital readmissions and physician costs are important and previously unreported contributors to the costs of SMM. Excess costs and LOS associated with SMM vary considerably by indication. Cost effects were larger than the LOS effects, indicating that SMM increases treatment intensity beyond increasing LOS, and decreasing SMM may have broader health and cost benefits than previously understood.

Abortion Access as a Racial Justice Issue The Dobbs decision rolls back fundamental rights for many people, and it is a direct assault on efforts to improve racial equity in health care. Indeed, ab...

Objective: Half of maternal deaths occur during the postpartum year, with data suggesting greater risks among Black, Indigenous, and people of color (BIPOC) and rural residents. Being insured after...

To examine the association between severe maternal morbidity (SMM) and infant health using the additional infant costs and length of stay (LOS) as markers of added clinical complexity. Secondary data analysis using California linked birth certificate-patient discharge data for 2009–2011 (N = 1,260,457). Regression models were used to estimate the association between SMM and infant costs and LOS. The 16,687 SMM-exposed infants experienced a $6550 (33%) increase in costs and a 0.7 (18%) day increase in LOS. Preterm infants had ($11,258 (18%) added costs and 1.3 days (8.1%) longer LOS) than term infants ($2539 (38%) added costs and 0.5 days (22%) longer LOS). SMM was associated with increased infant costs and LOS, suggesting that SMM may have adverse health effects for infants, including term infants. The relatively larger effect on costs indicates an increase in treatment intensity (clinical severity) greater than additional LOS.

<h2>Abstract</h2><h3>Objective</h3><p>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.</p><h3>Design</h3><p>Retrospective observational study.</p><h3>Setting</h3><p>Online questionnaire of women who gave birth in the United States.</p><h3>Participants</h3><p>Women (<i>N</i> = 1,711) with histories of cesarean and subsequent births within 5 years of participating.</p><h3>Methods</h3><p>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.</p><h3>Results</h3><p>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 (<i>p</i> = .88). More rural participants than metropolitan participants reported travel times of more than 60 minutes to give birth (<i>p</i> < .001), and fewer had obstetricians (<i>p</i> = .002) or doulas (<i>p</i> = .03). Rural participants from racialized groups experienced significantly less respectful maternity care than White, non-Hispanic rural participants and all metropolitan participants (<i>p</i> = .04). Qualitative data illustrating the main findings are included.</p><h3>Conclusions</h3><p>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.</p>

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 ob...

Introduction: Racial inequities in birth outcomes persist in the United States. Doula care may help to decrease inequities and improve some perinatal health indicators, but access remains a challenge. Recent doula-related state legislative action seeks to improve access, but the prioritization of equity is unknown. We reviewed recent trends in doula-related legislation and evaluated the extent to which new legislation addresses racial health equity. Methods: We conducted a landscape analysis of the LegiScan database to systematically evaluate state legislation mentioning the word “doula” between 2015 and 2020. We identified and applied nine criteria to assess the equity focus of the identified doula-related legislative proposals. Our final sample consisted of 73 bills across 24 states. Results: We observed a three-fold increase in doula-related state legislation introduced over the study period, with 15 bills proposed before 2019 and 58 proposed in 2019–2020. Proposed policies varied widely in content and scope, with 53.4% focusing on Medicaid reimbursement for doula care. In total, 12 bills in 7 states became law. Seven of these laws (58.3%) contained measures for Medicaid reimbursement for doula services, but none guaranteed a living wage based on the cost of living or through consultation with doulas. Only two states (28.6%; Virginia and Oregon) that passed Medicaid reimbursement for doulas also addressed other racial equity components. Conclusions: There has been an increase in proposed doula-related legislation between 2015 and 2020, but racial health equity is not a focus among the laws that passed. States should consider using racial equity assessments to evaluate proposed doula-related legislation.

<h3>Importance</h3><p>Timely access to clinically appropriate obstetric services is critical to the provision of high-quality perinatal care.</p><h3>Objective</h3><p>To examine the geographic distribution, proximity, and urban adjacency of US obstetric hospitals by annual birth volume.</p><h3>Design, Setting, and Participants</h3><p>This retrospective population-based cohort study identified US hospitals with obstetric services using the American Hospital Association (AHA) Annual Survey of Hospitals and Centers for Medicare &amp; Medicaid provider of services data from 2010 to 2018. Obstetric hospitals with 10 or more births per year were included in the study. Data analysis was performed from November 6, 2020, to April 5, 2021.</p><h3>Exposure</h3><p>Hospital birth volume, defined by annual birth volume categories of 10 to 500, 501 to 1000, 1001 to 2000, and more than 2000 births.</p><h3>Main Outcomes and Measures</h3><p>Outcomes assessed by birth volume category were percentage of births (from annual AHA data), number of hospitals, geographic distribution of hospitals among states, proximity between obstetric hospitals, and urban adjacency defined by urban influence codes, which classify counties by population size and adjacency to a metropolitan area.</p><h3>Results</h3><p>The study included 26 900 hospital-years of data from 3207 distinct US hospitals with obstetric services, reflecting 34 054 951 associated births. Most infants (19 327 487 [56.8%]) were born in hospitals with more than 2000 births/y, and 2 528 259 (7.4%) were born in low-volume (10-500 births/y) hospitals. More than one-third of obstetric hospitals (37.4%; 10 064 hospital-years) were low volume. A total of 46 states had obstetric hospitals in all volume categories. Among low-volume hospitals, 18.9% (1904 hospital-years) were not within 30 miles of any other obstetric hospital and 23.9% (2400 hospital-years) were within 30 miles of a hospital with more than 2000 deliveries/y. Isolated hospitals (those without another obstetric hospital within 30 miles) were more frequently low volume, with 58.4% (1112 hospital-years) located in noncore rural areas.</p><h3>Conclusions and Relevance</h3><p>In this cohort study, marked variations were found in birth volume, geographic distribution, proximity, and urban adjacency among US obstetric hospitals from 2010 to 2018. The findings related to geographic isolation and rural-urban distribution of low-volume obstetric hospitals suggest the need to balance proximity with volume to optimize effective referral and access to high-quality perinatal care.</p>

Nearly 20% of US residents, an estimated 65 million people, live in small towns and sparsely populated areas that the Census Bureau designates as rural; this proportion of rural residents has increased slightly since 2016. Whilethetiredadagethatruralresidentsare"older,poorer, and sicker" has been true for decades and remains so, it masks the wide range of rural US people and places. Rural residents are diverse along numerous dimensions: sex, age, family structure, sexual orientation, socioeconomic status, and occupation. One in 5 rural residents is Black, Indigenous, or a Person of Color, and that proportion is increasing. Improving rural health requires policy solutions to work for the US/Mexico border region, frontier Alaska,theGreatPlains,thesouthernBlackBelt,themoun-tainous Appalachian range, and many other places. The COVID-19 pandemic has highlighted deep and enduring inadequacies of health care services and policy decisions in rural communities. As of December 5, 2020, the COVID-19-related death rate was 7.8 per 100 000 people in nonmetropolitan counties, compared with 3.5 per 100 000 people in metropolitan counties. 1 Some of the highest COVID-19 infection and death rates in the US are among rural residents. COVID-19 is not creating these inequities but has revealed the depths of long-standing failures to ensure equitable opportunities for health, regardless of geography , socioeconomic status, or demographics. As the US emerges from the COVID-19 pandemic, there is opportunity for broad, bold, bipartisan policies to improvethelivesofruralresidents.Manyruralhealthpolicy efforts focus on bolstering the health care delivery system , and for good reason. The number of rural hospitals is declining; 135 rural hospitals (6.5% of a total of 2083) have closed since 2010, 19 in 2020 alone. 2 The number of ruralhospitalclosureshasincreasednearlyeveryyearsince 2010,and453remainingruralhospitalsareconsideredvul-nerable to closure, as determined by financial and operational data. 3 Rural hospitals in states that did not expand Medicaid under the Affordable Care Act are at particular risk, with 52% of rural hospitals in those states operating with a negative profit margin (vs 44% in Medicaid expansion states). 3 Currently, metropolitan and nonmetropoli-tan counties have similar numbers of hospital beds per capita(approximately 24/100 000), but hospitals in nonmetropolitan counties have less access to specialty services, including fewer intensive care units and declining access to obstetric services. 4,5 Additionally, work-forceshortagesareapersistentchallenge.AsofSeptember 30, 2020, 62% of the 7203 Medical Health Professional Shortage Areas across the US were in rural communities. 6 In short, rural residents do not have adequate access to health care and have worse health status. Rural residents experience systematic disadvantages because of structural urbanism. 7 That is, most policies are based on the needs of the urban majority, rather than the distinct needs of rural residents. Sustainable policy must be grounded in rural reality, which involve the unique assets and challenges in rural places, well-known to rural people. Evidence indicates that policies to improve rural healthmustbeproportionatelyfocusedonsocialandstruc-tural factors outside of the hospital or clinic. For example, a recent analysis found that geographic differences in infant mortality were not explained by individual maternal behaviorsorhealthsystemsfactorsbutratherbysocioeco-nomic disadvantage and poor community health. 8 Additionally , suicide rates in rural areas are 25% higher than those in urban areas (with rates of 17.6 in large metropolitan areas vs 22.1 in rural counties, per 100 000), and highest risks occur in rural counties with more gun shops, lower social capital, and lower rates of health insurance. 9 These factorsareamenabletopolicyintervention. 9 TheBidenad-ministrationandCongressshouldprioritize policies that reflect the needs of rural residents to halt the pernicious effects of structural urbanism. Two major policy strategies-one administrative and one legislative-may represent crucial initial steps toward improving rural health: The new presidential administration should seek rural representation on regulations and in policy implementation, and Congress should pursue evidence based policy options to improve rural community infrastructure, starting with broadband internet. To improve rural health, the executive branch must ensure rural representation in the establishment of regulations and implementation of programs and policies. Achieving rural representation means that people who live and work in rural areas should be included in key decision making roles and on advisory panels and bodies. This could be implemented by requiring reporting on the demographics of decision-makers, including whether they are residents of rural areas. The Biden administration has embraced a focus on sex and racial/ethnic diversity among its leadership in assembling a Cabinet and is well-positioned to adopt a clear stance on rural representation. Rather than creating post hoc rural-focused fixes (eg, the Critical Access Hospital Program) to reme-diate problems created by urban-focused decisions on health care access, financing, and quality, rural perspectives should be included in all policy efforts from the start. The presence of rural representation is essential for One in 5 rural residents is Black, Indigenous, or a Person of Color, and that proportion is increasing.

Racial and ethnic inequities in health are a national crisis requiring engagement across a range of factors, including the health care workforce. Racial inequities in maternal and infant health are...

<p> <b>Objective</b> The aim of the study is to determine the relationship between a hospital's provision of subspecialty neonatal and maternal care. Specifically, we sought to understand where women with high-risk maternal conditions received intrapartum care and estimate the potential transfer burden for those with maternal high-risk conditions delivering at hospitals without subspecialty maternal care.</p> <p> <b>Study Design</b> This is a descriptive study using data from 2015 State Inpatient Databases and the American Hospital Association Annual Survey. Characteristics were compared between hospitals based on the concordance of their maternal and neonatal care. The incidences of high-risk maternal conditions (pre-eclampsia with severe features, placenta previa with prior cesarean delivery, cardiac disease, pulmonary edema, and acute liver failure) were compared. To determine the potential referral burden, the percent of women with high-risk conditions delivering at a hospital without subspecialty maternal care but delivering in a county with a hospital with subspecialty maternal care was calculated.</p> <p> <b>Results</b> The analysis included 486,398 women who delivered at 544 hospitals, of which 104 (19%) and 182 (33%) had subspecialty maternal and neonatal care, respectively. Ninety-eight hospitals provided both subspecialty maternal and neonatal care; however, 84 hospitals provided only subspecialty neonatal care but no subspecialty maternal care. Among high-risk maternal conditions examined, approximately 65% of women delivered at a hospital with subspecialty maternal care. Of the remainder who delivered at a hospital without subspecialty maternal care, one-third were in a county where subspecialty care was present. For women with high-risk conditions who delivered in a county without subspecialty maternal care, the median distance to the closest county with subspecialty care was 52.8 miles (IQR 34.3–87.7 miles).</p> <p> <b>Conclusion</b> Approximately 50% of hospitals with subspecialty neonatal care do not provide subspecialty maternal care. This discordance may present a challenge when both high-risk maternal and neonatal conditions are present.</p> <p> <b>Key Points</b> </p>

Purpose: For reproductive-age women, medications for opioid use disorder (OUD) decrease risk of overdose death and improve outcomes but are underutilized. Our objective was to provide a qualitative description of reproductive-age women's experiences of seeking an appointment for medications for OUD. Methods: Trained female callers placed telephone calls to a representative sample of publicly listed opioid treatment clinics and buprenorphine providers in Florida, Kentucky, Massachusetts, Michigan, Missouri, North Carolina, Tennessee, Virginia, Washington, and West Virginia to obtain appointments to receive medication for OUD. Callers were randomly assigned to be pregnant or non-pregnant and have private or Medicaid-based insurance to assess differences in the experiences of access by these characteristics. The callers placed 28,651 uniquely randomized calls, 10,117 to buprenorphine-waivered prescribers and 754 to opioid treatment programs. Open-ended, qualitative data were obtained from the callers about the access experiences and were analyzed using a qualitative, iterative inductive-deductive approach. From all 28,651 total calls, there were 17,970 unique free-text comments to the question “Please give an objective play-by-play of the description of what happened in this conversation.” Findings: Analysis demonstrated a common path to obtaining an appointment. Callers frequently experienced long hold times, multiple transfers, and difficult interactions. Clinic receptionists were often mentioned as facilitating or obstructing access. Pregnant callers and those with Medicaid noted more barriers. Obtaining an appointment was commonly difficult even for these persistent, trained callers. Conclusions: Interventions are needed to improve the experiences of reproductive-age women as they enter care for OUD, especially for pregnant women and those with Medicaid coverage.

Increases in postpartum maternal deaths, including a substantial number associated with behavioural health conditions, are a public health crisis and have contributed to overall increases in matern...

Pernicious racial disparities in birth outcomes in the United States have their roots in structural racism—the systematic allocation of opportunities and resources based on race. These inequities, caused by systemic factors which contribute to lower quality of care, negatively impact the lives of Blacks/African Americans. The development of new maternity care models hold potential to reduce disparities and costs by focusing on the root cause of racism. Roots Community Birth Center is an African American-owned, midwife-led freestanding birth center in North Minneapolis. Roots provides a culturally-centered model of care during pregnancy, childbirth, and the postpartum period. The culturally-centered care model utilized by Roots Community Birth Center offers culturally-centered care that is community based, accepts Medicaid beneficiaries, and provides prenatal and postpartum visits that are customized to the needs of the birthing individual. Like other institutions, this birth center faces the financial challenges associated with maternity care payment models and inadequate Medicaid reimbursement, challenges that directly interfere with the center's culturally-centered care model which advocates for longer prenatal visits and close follow-up postpartum. The birth center model of care has proven effective; over the last four years Roots has had 284 families with zero preterm births. The culturally-centered care model used by Roots is not currently well-supported by maternity care payment models that were designed in large part to reflect typical care provided by obstetricians and hospitals.

Achieving racial equity in childbirth care is critical to the health and well-being of our nation. Black infants are more than twice as likely as White infants to die before reaching their first birthday, and Black individuals who experience reproduction are 3-4 times more likely to experience a complication or death related to childbirth. 1 These inequities are one clear manifestation of structural racism-a form of racism that lacks an identifiable perpetrator but is instead the codification and legalization of society's unequal allocation of resources and opportunity based on an established racial hierarchy. 2,3 Clinical care during pregnancy and childbirth is an important determinant of perinatal-infant outcomes; however , for Black birthing people, care in the medical context does not consistently meet their clinical needs. 4 In addition, racial discrimination and experiences of interpersonal racism such as implicit racial bias and microaggressions during clinical encounters create disproportionate barriers to high-quality , respectful, patient-centered care experienced by Black people. 5-8 Perinatal care, as currently designed and delivered in most settings in the United States, has proven woefully inadequate for addressing structural and interpersonal racism in the day-today experiences of Black birthing people and in their encounters with the health care system. 8-11 Health care services that are grounded in relationships that acknowledge dynamics of power and that foster mutual respect may help shift pernicious patterns of racial inequity in perinatal care and childbirth. The patient-clinician relationship is central to achieving high-quality perinatal care. Indeed, relationships provide the context for many important functions and activities in health care. 12 Relationship-centered care-a theoretical concept introduced in 2006 by Beach and colleagues, can be defined as care in which all participants appreciate the importance of their relationships with one another. 12 To date, few scholars have explored this concept, and despite a considerable body of relationship-centered care literature devoted to prenatal and perinatal care, there is very little written about what constitutes relationship-centered care specifically for Black birthing people. 13 Racial identity and experiences of racism influence the care Black birthing people desire-this suggests that meaningful care for this population needs to incorporate not only a relationship-centered care approach, but also anti-racism-based theoretical approaches that focus specifically on the experiences of Black parenthood. 10,14 This call to action describes Beach and colleague's four principles of relationship-centered care through a critical race lens in the context of pregnancy and childbirth care. Taken together, the two concepts-relationship-centered care and critical race theory-have the potential to powerfully reduce racism's impact on childbirth outcomes for Black birth-ing individuals, infants, and families.