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.

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. (Am J Public Health. Published online ahead of print July 16, 2020: e1-e3. doi:10.2105/AJPH.2020.305695).

<p>The growing ranks of nurse practitioners (NPs) in rural areas of the United States have the potential to help alleviate existing primary care shortages. This study uses a nationwide source of claims- and EHR-data from 2017 to construct measures of NP clinical autonomy and complexity of care. Comparisons between rural and urban primary care practices reveal greater clinical autonomy for rural NPs, who were more likely to have an independent patient panel, to practice with less physician supervision, and to prescribe Schedule II controlled substances. In contrast, rural and urban NPs provided care of similar complexity. These findings provide the first claims- and EHR-based evidence for the commonly held perception that NPs practice more autonomously in rural areas than in urban areas.</p>

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.

This study examines racial and ethnic differences in self-rated health among rural residents and whether these differences can be explained by socio-demographic characteristics. We used data from the 2011–2017 National Health Interview Survey to assess differences in self-rated health by race and ethnicity among rural residents (living in non-metropolitan counties; n = 46,883). We used logistic regression analyses to estimate the odds of reporting fair/poor health after adjusting for individual socio-demographic characteristics. Non-Hispanic Black and American Indian rural residents reported worse self-rated health than their non-Hispanic White counterparts (25.8% and 20.8% reporting fair/poor health, respectively, vs. 14.8%; p < 0.001). After adjusting for socio-demographic characteristics, disparities remained for non-Hispanic Black rural residents (Adjusted Odds Ratio = 1.55; 95% CI 1.36, 1.76). This study suggests more attention is required to address inequities among rural people and to develop policies to address structural racism and improve the health of all rural residents.