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.

Tremendous advances in women's health have occurred in the 30 years since the launch of Women's Health Issues, yet not all women have benefited equally (Vyas et al., 2021). Inequities in health outcomes by race, ethnicity, sexual orientation, and gender identity reflect structural racism and other systemic in-equities, as well as institutional and interpersonal racism, and other intersecting forms of discrimination that individuals encounter as they seek health care. Today, we are deep in the midst of a national and global reckoning around racism, other forms of inequality and discriminationdincluding but not limited to sexism, heterosexism, and transphobia, and health inequitiesdas well as a pandemic that demonstrates the horrific consequences of unjust structures, systems, institutions, and practices. This article describes how the editorial board and staff of Women's Health Issues approach these complex topics and steps we are undertaking to advance equity. A Context of Injustice In the field of women's health, we acknowledge both the intersecting forms of oppression that shape the experiences of women with multiple marginalized identities and the fact that cisgender women are not the only ones who need "women's" health care and research. Black feminist and other critical scholars have explained how our laws and cultural standards both implicitly and explicitly reinforce White supremacy and other forms of oppression (Collins, 1990; Combahee River Collective,

<h3>Importance</h3><p>Little is known about the quality of postpartum care or disparities in the content of postpartum care associated with health insurance, rural or urban residency, and race and ethnicity.</p><h3>Objectives</h3><p>To examine receipt of recommended postpartum care content and to describe variations across health insurance type, rural or urban residence, and race and ethnicity.</p><h3>Design, Settings, and Participants</h3><p>This cross-sectional survey of patients with births from 2016 to 2019 used data from the Pregnancy Risk Assessment Monitoring System (43 states and 2 jurisdictions). A population-based sample of patients conducted by state and local health departments in partnership with the Centers for Disease Control and Prevention were surveyed about maternal experiences 2 to 6 months after childbirth (mean weighted response rate, 59.9%). Patients who attended a postpartum visit were assessed for content at that visit. Analyses were performed November 2021 to July 2022.</p><h3>Exposures</h3><p>Medicaid or private health insurance, rural or urban residence, and race and ethnicity (non-Hispanic White or racially minoritized groups).</p><h3>Main Outcomes and Measures</h3><p>Receipt of 2 postpartum care components recommended by national quality standards (depression screening and contraceptive counseling), and/or other recommended components (smoking screening, abuse screening, birth spacing counseling, eating and exercise discussions) with estimated risk-adjusted predicted probabilities and percentage-point (pp) differences.</p><h3>Results</h3><p>Among the 138 073 patient-respondents, most (59.5%) were in the age group from 25 to 34 years old; 59 726 (weighted percentage, 40%) were insured by Medicaid; 27 721 (15%) were rural residents; 9718 (6%) were Asian, 24 735 (15%) were Black, 22 210 (15%) were Hispanic, 66 323 (60%) were White, and fewer than 1% were Indigenous (Native American/Alaska Native) individuals. Receipt of both depression screening and contraceptive counseling both significantly lower for Medicaid-insured patients (1.2 pp lower than private; 95% CI, –2.1 to –0.3), rural residents (1.3 pp lower than urban; 95% CI, –2.2 to –0.4), and people of racially minoritized groups (0.8 pp lower than White individuals; 95% CI, –1.6 to –0.1). The highest receipt of these components was among privately insured White urban residents (80%; 95% CI, 79% to 81%); the lowest was among privately insured racially minoritized rural residents (75%; 95% CI, 72% to 78%). Receipt of all other components was significantly higher for Medicaid-insured patients (6.1 pp; 95% CI, 5.2 to 7.0), rural residents (1.1 pp; 95% CI, 0.1 to 2.0), and people of racially minoritized groups (8.5 pp; 95% CI, 7.7 to 9.4). The highest receipt of these components was among Medicaid-insured racially minoritized urban residents (34%; 95% CI, 33% to 35%), the lowest was among privately insured White urban residents (19%; 95% CI, 18% to 19%).</p><h3>Conclusions and Relevance</h3><p>The findings of this cross-sectional survey of postpartum individuals in the US suggest that inequities in postpartum care content were extensive and compounded for patients with multiple disadvantaged identities. Examining only 1 dimension of identity may understate the extent of disparities. Future studies should consider the content of postpartum care visits.</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...

<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.