We identified obstetric service status for every rural and urban short-term acute care hospital in every US state. During 2010–22, seven states had at least 25 percent of hospitals close their obst...

<p>Rural people and communities experience disproportionate health and social risks in the United States, and university systems, especially those that are federal land-grant institutions, have an obligation to direct academic attention and resources to all communities, not just the predominantly urban areas where most flagship academic institutions are located. In 2020, the University of Minnesota Rural Health Program established the Rural Collective, a forum for networking and collaboration on rural issues across the university system. We conducted a survey of Rural Collective members in summer 2024 to highlight aspects of the Rural Collective that members find most beneficial. Survey results (N = 66) indicated that members found virtual meetings and weekly emails to be beneficial features of the program. Nearly 90% reported that they have learned something new about rural work since joining, and more than 71% reported that joining the Rural Collective has led to a new connection or collaboration in their rural-focused work. Importantly, 96% of respondents believed that the Rural Collective is addressing an important need at the university, a finding that may be relevant for other institutions where there are obligations and potentially unmet needs related to rural community engagement, rural health promotion, and rural-focused academic work.</p>

Objective: To develop a method of consistently identifying interfacility transfers (IFTs) in Medicare Claims using patients with ST-Elevation Myocardial Infarction (STEMI) as an example. Data Sources/Study Setting: 100% Medicare inpatient and outpatient Standard Analytic Files and 5% Carrier Files, 2011–2020. Study Design: Observational, cross-sectional comparison of patient characteristics between proposed and existing methods. Data Collection/Extraction Methods: We limited to patients aged 65+ with STEMI diagnosis using both proposed and existing methods. Principal Findings: We identified 62,668 more IFTs using the proposed method (86,128 versus 23,460). A separately billable interfacility ambulance trip was found for more IFTs using the proposed than existing method (86% vs. 79%). Compared with the existing method, transferred patients under the proposed method were more likely to live in rural (p < 0.001) and lower income (p < 0.001) counties and were located farther away from emergency departments, trauma centers, and intensive care units (p < 0.001). Conclusions: Identifying transferred patients based on two consecutive inpatient claims results in an undercount of IFTs and under-represents rural and low-income patients.

Objective: To examine racial inequities in low-risk and high-risk (or “medically appropriate”) cesarean delivery rates in New Jersey during the era surrounding the United States cesarean surge and peak. Study Setting and Design: This retrospective repeated cross-sectional study examined the universe of childbirth hospitalizations in New Jersey from January 1, 2000 through September 30, 2015. We estimate the likelihood of cesarean delivery by maternal race and ethnicity, with mixed-level logistic regression models, stratified by cesarean risk level designated by the Society of Maternal Fetal Medicine (SMFM). Data Sources and Analytic Sample: We used all-payer hospital discharge data from the Healthcare Cost and Utilization Project's State Inpatient Discharge Database and linked this data to the American Hospital Association Annual Survey. ZIP-code Tabulation Area (ZCTA)-level racialized economic segregation index data were from the 2007–2011 American Community Survey. We identified 1,604,976 statewide childbirth hospitalizations using International Classification of Diseases-9-CM (ICD-9) diagnosis and procedure codes and Diagnosis-Related Group codes, and created an indicator of cesarean delivery using ICD-9 codes. Principal Findings: Among low-risk deliveries, Black patients, particularly those in the age group of 35–39 years, had higher predicted probabilities of giving birth via cesarean than White people in the same age categories (Black-adjusted predicted probability = 24.0%; vs. White-adjusted predicted probability = 17.3%). Among high-risk deliveries, Black patients aged 35 to 39 years had a lower predicted probability (by 2.7 percentage points) of giving birth via cesarean compared with their White counterparts. Conclusions: This study uncovered a lack of medically appropriate cesarean delivery for Black patients, with low-risk Black patients at higher odds of cesarean delivery and high-risk Black patients at lower odds of cesarean than their White counterparts. The significant Black-White inequities highlight the need to address misalignment of evidence-based cesarean delivery practice in the efforts to improve maternal health equity. Quality metrics that track whether cesareans are provided when medically needed may contribute to clinical and policy efforts to prevent disproportionate maternal morbidity and mortality among Black patients.

Purpose: Intimate partner violence (IPV) is elevated among rural residents and contributes to maternal morbidity and mortality. Postpartum health insurance expansion efforts could address multiple causes of maternal morbidity and mortality, including IPV. The objective of this study was to describe the relationship between perinatal health insurance, IPV, and postpartum abuse screening among rural US residents. Methods: Using 2016-2020 data on rural residents from the Pregnancy Risk Assessment Monitoring System, we assessed self-report of experiencing physical violence by an intimate partner and rates of abuse screening at postpartum visits. Health insurance at childbirth and postpartum was categorized as private, Medicaid, or uninsured. We also measured insurance transitions from childbirth to postpartum (continuous private, continuous Medicaid, Medicaid to private, and Medicaid to uninsured). Findings: IPV rates varied by health insurance status at childbirth, with the highest rates among Medicaid beneficiaries (7.7%), compared to those who were uninsured (1.6%) or privately insured (1.6%). When measured by insurance transitions, the highest IPV rates were reported by those with continuous Medicaid coverage (8.6%), followed by those who transitioned from Medicaid at childbirth to private insurance (5.3%) or no insurance (5.9%) postpartum. Nearly half (48.1%) of rural residents lacked postpartum abuse screening, with the highest proportion among rural residents who were uninsured at childbirth (66.1%) or postpartum (52.1%). Conclusion: Rural residents who are insured by Medicaid before or after childbirth are at elevated risk for IPV. Medicaid policy efforts to improve maternal health should focus on improving detection and screening for IPV among rural residents. K E Y W O R D S health insurance, intimate partner violence, maternal health, PRAMS, rural health This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Introduction: Access to pregnancy-related and childbirth-related health care for rural residents is limited by health workforce shortages in the United States. Although midwives are key pregnancy and childbirth care providers, the current landscape of the rural midwifery workforce is not well understood. The goal of this analysis was to describe the availability of local midwifery care in rural US communities. Methods: We developed and conducted a national survey of rural US hospitals with current or recently closed childbirth services. Maternity unit managers or administrators at 292 rural hospitals were surveyed from March to August 2021, with 133 hospitals responding (response rate 46%; 93 currently offering childbirth services, 40 recently closed childbirth services). This cross-sectional analysis describes whether rural hospitals with current or prior childbirth services had midwifery care with certified nurse-midwives available locally and whether rural communities with and without midwifery care differed by hospital-level and county-level characteristics. Results: Among hospitals surveyed, 55% of those with current and 75% of those with prior childbirth services reported no locally available midwifery care. Of the 93 rural communities with current hospital-based childbirth services, those without midwifery care were more likely to have lower populations (37% vs 33%); majority populations that were Black, Indigenous, and people of color (24% vs 10%); and hospitals where at least 50% of births were Medicaid funded (77% vs 64%), compared with communities with midwifery care. Conversely, communities with midwifery care more often had greater than 30% of patients traveling more than 30 miles for hospital-based childbirth services (38% vs 28%). Discussion: More than half of rural hospitals surveyed reported no locally available midwifery care, and availability differed by hospital-level and county-level characteristics. Efforts to ensure pregnancy and childbirth care access for rural birthing people should include attention to the availability of local midwifery care.

<h2>Summary</h2><p>Societal systems act individually and in combination to create and perpetuate structural racism through both policies and practices at the local, state, and federal levels, which, in turn, generate racial and ethnic health disparities. Both current and historical policy approaches across multiple sectors—including housing, employment, health insurance, immigration, and criminal legal—have the potential to affect child health equity. Such policies must be considered with a focus on structural racism to understand which have the potential to eliminate or at least attenuate disparities. Policy efforts that do not directly address structural racism will not achieve equity and instead worsen gaps and existing disparities in access and quality—thereby continuing to perpetuate a two-tier system dictated by racism. In Paper 2 of this Series, we build on Paper 1's summary of existing disparities in health-care delivery and highlight policies within multiple sectors that can be modified and supported to improve health equity, and, in so doing, improve the health of racially and ethnically minoritised children.</p>

Objective: U.S. breastfeeding outcomes consistently fall short of public health targets, with lower rates among rural and low-income people, as well as participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The U.S. Department of Agriculture funded a subset of local WIC agencies in Minnesota to implement Breastfeeding Peer Counseling Programs (BFPCs) aimed at improving breastfeeding rates. We examined the impact of BFPCs on breastfeeding rates among WIC participants in Greater Minnesota (outside the Minneapolis–St. Paul metropolitan area). Methods: We used data from the Minnesota WIC Information System for the years 2012 through 2019 to estimate the impact of peer counseling on breastfeeding duration using difference-in-differences models. Additionally, we examined results among rural counties and assessed the possibility of spillover effects by stratifying whether a county without BFPCs bordered one with BFPCs. Results: Availability of BFPCs resulted in a 3.1 to 3.4 percentage-point increase in breastfeeding rates at 3 months and a 3.2 to 3.7 percentage-point increase in breastfeeding rates at 6 months among WIC participants in Greater Minnesota. Among rural counties, results showed a statistically significant 4.1 to 5.2 percentage-point increase in breastfeeding duration rates. Both border and nonborder counties experienced positive impacts of BFPCs on breastfeeding rates, suggesting wide-ranging program spillover effects. Conclusions: BFPCs had a significant positive impact on breastfeeding duration. Findings indicate an opportunity for improving rural breastfeeding rates through increased funding for WIC BFPCs.

Objective: To implement use of obstetric (OB) hospitalist telemedicine services (TeleOB) to support clinicians facing OB emergencies in low-resource hospital settings. Methods: TeleOB was staffed b...

<h3>Importance</h3><p>Pursuant to the Families First Coronavirus Response Act (FFCRA), continuous Medicaid eligibility during the COVID-19 public health emergency (PHE) created a de facto national extension of pregnancy Medicaid eligibility beyond 60 days postpartum.</p><h3>Objective</h3><p>To evaluate the association of continuous Medicaid eligibility with postpartum health insurance, health care use, breastfeeding, and depressive symptoms.</p><h3>Design, Setting, and Participants</h3><p>This cohort study using a generalized difference-in-differences design included 21 states with continuous prepolicy (2017-2019) and postpolicy (2020-2021) participation in the Pregnancy Risk Assessment Monitoring System (PRAMS).</p><h3>Exposures</h3><p>State-level change in Medicaid income eligibility after 60 days postpartum associated with the FFCRA measured as a percent of the federal poverty level (FPL; ie, the difference in 2020 income eligibility thresholds for pregnant people and low-income adults/parents).</p><h3>Main Outcomes and Measures</h3><p>Health insurance, postpartum visit attendance, contraceptive use (any effective method; long-acting reversible contraceptives), any breastfeeding and depressive symptoms at the time of the PRAMS survey (mean [SD], 4 [1.3] months postpartum).</p><h3>Results</h3><p>The sample included 47 716 PRAMS respondents (64.4% aged &lt;30 years; 18.9% Hispanic, 26.2% non-Hispanic Black, 36.3% non-Hispanic White, and 18.6% other race or ethnicity) with a Medicaid-paid birth. Based on adjusted estimates, a 100% FPL increase in postpartum Medicaid eligibility was associated with a 5.1 percentage point (pp) increase in reported postpartum Medicaid enrollment, no change in commercial coverage, and a 6.6 pp decline in uninsurance. This represents a 40% reduction in postpartum uninsurance after a Medicaid-paid birth compared with the prepolicy baseline of 16.7%. In subgroup analyses by race and ethnicity, uninsurance reductions were observed only among White and Black non-Hispanic individuals; Hispanic individuals had no change. No policy-associated changes were observed in other outcomes.</p><h3>Conclusions and Relevance</h3><p>In this cohort study, continuous Medicaid eligibility during the COVID-19 PHE was associated with significantly reduced postpartum uninsurance for people with Medicaid-paid births, but was not associated with postpartum visit attendance, contraception use, breastfeeding, or depressive symptoms at approximately 4 months postpartum. These findings, though limited to the context of the COVID-19 PHE, may offer preliminary insight regarding the potential impact of post-pandemic postpartum Medicaid eligibility extensions. Collection of longer-term and more comprehensive follow-up data on postpartum health care and health will be critical to evaluating the effect of ongoing postpartum policy interventions.</p>

A growing number of studies are using birth certificate data, despite data-quality concerns, to study maternal morbidity and associated disparities. We examined whether conclusions about the incidence of maternal morbidity, including Black-White disparities, differ between birth certificate data and hospitalization data. Using linked birth certificate and hospitalization data from California and Michigan for 2018 (N=543,469), we found that maternal morbidity measures using birth certificate data alone are substantially underreported and have poor validity. Furthermore, the degree of underreporting in birth certificate data differs between Black and White individuals and results in erroneous inferences about disparities. Overall, Black-White disparities were more modest in the birth certificate data compared with the hospitalization data. Birth certificate data alone are inadequate for studies of maternal morbidity and associated racial disparities.

Objective: To describe rates and predictors of perinatal intimate partner violence (IPV) and rates and predictors of not being screened for abuse among rural and urban IPV victims who gave birth. Data Sources and Study Setting: This analysis utilized 2016–2020 Pregnancy Risk Assessment Monitoring System (PRAMS) data from 45 states and three jurisdictions. Study Design: This is a retrospective, cross-sectional study using multistate survey data. Data Collection/Extraction Methods: This analysis included 201,413 survey respondents who gave birth in 2016–2020 (n = 42,193 rural and 159,220 urban respondents). We used survey-weighted multivariable logistic regression models, stratified by rural/urban residence, to estimate adjusted predicted probabilities and 95% confidence intervals (CIs) for two outcomes: (1) self-reported experiences of IPV (physical violence by a current or former intimate partner) and (2) not receiving abuse screening at health care visits before, during, or after pregnancy. Principal Findings: Rural residents had a higher prevalence of perinatal IPV (4.6%) than urban residents (3.2%). Rural respondents who were Medicaid beneficiaries, 18–35 years old, non-Hispanic white, Hispanic (English-speaking), or American Indian/Alaska Native had significantly higher predicted probabilities of experiencing perinatal IPV compared with their urban counterparts. Among respondents who experienced perinatal IPV, predicted probabilities of not receiving abuse screening were 21.3% for rural and 16.5% for urban residents. Predicted probabilities of not being screened for abuse were elevated for rural IPV victims who were Medicaid beneficiaries, 18–24 years old, or unmarried, compared to urban IPV victims with those same characteristics. Conclusions: IPV is more common among rural birthing people, and rural IPV victims are at higher risk of not being screened for abuse compared with their urban peers. IPV prevention and support interventions are needed in rural communities and should focus on universal abuse screening during health care visits and targeted support for those at greatest risk of perinatal IPV.

Measures of perinatal care quality and outcomes often focus on either the birth parent or the infant. We used linked vital statistics and hospital discharge data to describe a dyadic measure (including both the birth parent and the infant) for perinatal care during the birth hospitalization. In this five-state cohort of 2010-18 births, 21.6 percent of birth parent-infant dyads experienced at least one complication, and 9.6 percent experienced a severe complication. Severe infant complications were eight times more prevalent than severe birth parent complications. Among birth parents with a severe complication, the co-occurrence of a severe infant complication ranged from 2 percent to 51 percent, whereas among infants with a severe complication, the co-occurrence of a severe birth parent complication was rare, ranging from 0.04 percent to 5 percent. These data suggest that measures, clinical interventions, public reporting, and policies focused on either the birth parent or the infant are incomplete in their assessment of a healthy dyad. Thus, clinicians, administrators, and policy makers should evaluate dyadic measures, incentivize positive outcomes for both patients (parent and infant), and create policies that support the health of the dyad.

The problem of medically underserved areas requires structural change, writes Katy Backes Kozhimannil Access to healthcare is an internationally recognised human right, but the United States is failing at honouring this right for people who are pregnant.1 Research documenting the scope and consequences of declining access to maternal healthcare, especially in rural areas, has been amassing over the past 10 years.23 News stories have followed, and policy makers have paid attention. In 2018 Congress passed the Improving Access to Maternity Care Act.4 Yet, despite evidence, media attention, and policy action, the situation isn’t getting better. Nowhere to Go: Maternity Care Deserts Across the US , a 2022 report from the non-profit organisation March of Dimes, highlighted ongoing and worsening gaps in access to care during pregnancy, childbirth, and the postpartum period, concentrated in rural and low income communities.5 For example, the report said that in 2022 more than 2.2 million women of reproductive age lived in counties with no maternity care access, an uptick since the organisation’s 2020 report—indicating that 15 933 women lost local maternity care access over those two years. The central role of social determinants in health outcomes is now widely acknowledged, yet research and recommendations still often focus on individual and clinical risk factors. The structural and political changes necessary to reverse inequitable resource allocations across various areas of healthcare in …

OBJECTIVE: To measure variation in delivery-related severe maternal morbidity (SMM) among individuals with Medicaid insurance by state and by race and ethnicity across and within states. METHODS: We conducted a pooled, cross-sectional analysis of the 2016-2018 TAF (Transformed Medicaid Statistical Information System Analytic Files). We measured overall and state-level rates of SMM without blood transfusion for all individuals with Medicaid insurance with live births in 49 states and Washington, DC. We also examined SMM rates among non-Hispanic Black and non-Hispanic White individuals with Medicaid insurance in a subgroup of 27 states (and Washington, DC). We generated unadjusted rates of composite SMM and the individual indicators of SMM that comprised the composite. Rate differences and rate ratios were calculated to compare SMM rates for non-Hispanic Black and non-Hispanic White individuals with Medicaid insurance. RESULTS: The overall rate of SMM without blood transfusion was 146.2 (95% CI 145.1-147.3) per 10,000 deliveries (N54,807,143). Rates of SMM ranged nearly threefold, from 80.3 (95% CI 71.4-89.2) per 10,000 deliveries in Utah to 210.4 (95% CI 184.6-236.1) per 10,000 deliveries in Wash-ington, DC. Non-Hispanic Black individuals with Medicaid insurance (n5629,774) experienced a higher overall rate of SMM (212.3, 95% CI 208.7-215.9) compared with non-Hispanic White individuals with Medicaid insurance (n51,051,459); (125.3, 95% CI 123.2-127.4) per 10,000 deliveries (rate difference 87.0 [95% CI 82.8-91.2]/10,000 deliveries ; rate ratio 1.7 [95% CI 1.7-1.7]). The leading individual indicator of SMM among all individuals with Medicaid insurance was eclampsia, although the leading indicators varied across states and by race and ethnicity. Many states were concordant in leading indicators among the overall, non-Hispanic Black, and non-Hispanic White populations (ie, in Oklahoma sepsis was the leading indicator for all three). Most states, however, were discordant in leading indicators across the three groups (ie, in Texas eclampsia was the leading indicator overall, pulmonary edema or acute heart failure was the leading indicator among the non-Hispanic Black population, and sepsis was the leading indicator among the non-Hispanic White population). CONCLUSION: Interventions aimed at reducing SMM and, ultimately, mortality among individuals with Med-icaid insurance may benefit from the data generated from this study, which highlights states that have the greatest burden of SMM, the differences in rates among non-Hispanic Black populations compared with non-Hispanic White populations, and the leading indicators of SMM overall, by state, and by race and ethnicity.

Research Objective: Similar to maternal mortality, the United States has experienced increases in the rates of severe maternal morbidity (SMM) and has pronounced racial/ethnic disparities in SMM, with non-Hispanic Black (NHB) women having twice the rate as non-Hispanic White (NHW) women. This study further examined these racial/ethnic disparities, looking for differences in costs, lengths of stay (LOS), and severity of SMM. Study Design: Secondary data analysis was performed using the CDC definition of SMM, including readmissions up to 42 days postpartum. GLM models with a gamma distribution and a log link, with and without hospital fixed-effects, were used to estimate the effect of SMM on costs and LOS, controlling for race/ethnicity, cesarean delivery, type of insurance, parity, maternal age and BMI, multiple births, and an obstetric severity index. Population Studied: California linked birth certificate-patient discharge data for 2009-2011. About 200 000 were excluded for missing charge data (almost all insured by Kaiser Permanente). Cost-to-charge ratios were used to estimate costs (including readmissions) after adjusting for inflation to December 2017 dollars. Mean DRG-specific reimbursement was used to estimate physician payments. The final N = 1 262 862. Principal Findings: SMM was observed in 1.34% of NHW and 2.62% of NHB. Adjusting for delivery method, among those deliveries with SMM, NHB women also had 38% longer LOS (5.1 vs 3.7 days) and 23% higher average costs per case ($19 507 vs $15 879) compared to NHW women. There were small racial/ethnic differences in the rates for the specific groups of diagnoses in the CDC definition of SMM, but NHB women had higher costs and LOS per case within almost all of these groups. Adjusting for risk, NHB women with SMM had costs that were 22% higher without and 17% higher with hospital fixed-effects. For LOS, these were 21% and 20%, respectively. These effects were slightly smaller (15% and 12% for costs and 14% and 13% for LOS, respectively) when the different indicators of SMM were controlled for, indicating that NHB women were somewhat more likely to have more serious types of SMM. Asian women experienced added costs that were similar to NHB women in models without hospital fixed-effects, but these differences were much smaller in the fixed-effects models. Conclusion(s): There are racial/ethnic disparities in the per-case costs and LOS among patients with SMM. The moderation of these effects for NHB women in the fixed-effects models indicates that some of the elevated costs and LOS are due to disparate quality of care at hospitals more likely to treat NHB women. This effect is even more pronounced for Asian women. Implications for Policy or Practice: These results indicate a key policy role for facility-based improvements and interventions. Additionally, the moderation of overall effects when the type of SMM is controlled for indicates that some of the added costs and LOS for NHB and Asian women are due to a higher prevalence of more serious types of SMM. This individual risk could also be shaped by broader social determinants of health as well as policies. Initiatives to reduce racial disparities in SMM should account for both individual risk (clinical complexity) and structural risk (hospital-and system-level factors)..

Importance: Identifying hospital factors associated with severe maternal morbidity (SMM) is essential to clinical and policy efforts. Objective: To assess associations between obstetric volume and SMM in rural and urban hospitals and examine whether these associations differ for low-risk and higher-risk patients. Design, Setting, and Participants: This retrospective cross-sectional study of linked vital statistics and patient discharge data was conducted from 2022 to 2023. Live births and stillbirths (≥20 weeks' gestation) at hospitals in California (2004-2018), Michigan (2004-2020), Pennsylvania (2004-2014), and South Carolina (2004-2020) were included. Data were analyzed from December 2022 to May 2023. Exposures: Annual birth volume categories (low, medium, medium-high, and high) for hospitals in urban (10-500, 501-1000, 1001-2000, and >2000) and rural (10-110, 111-240, 241-460, and >460) counties. Main Outcome and Measures: The main outcome was SMM (excluding blood transfusion); covariates included age, payer status, educational attainment, race and ethnicity, and obstetric comorbidities. Analyses were stratified for low-risk and higher-risk obstetric patients based on presence of at least 1 clinical comorbidity. Results: Among more than 11 million urban births and 519 953 rural births, rates of SMM ranged from 0.73% to 0.50% across urban hospital volume categories (high to low) and from 0.47% to 0.70% across rural hospital volume categories (high to low). Risk of SMM was elevated for patients who gave birth at rural hospitals with annual birth volume of 10 to 110 (adjusted risk ratio [ARR], 1.65; 95% CI, 1.14-2.39), 111 to 240 (ARR, 1.37; 95% CI, 1.10-1.70), and 241 to 460 (ARR, 1.26; 95% CI, 1.05-1.51), compared with rural hospitals with greater than 460 births. Increased risk of SMM occurred for low-risk and higher-risk obstetric patients who delivered at rural hospitals with lower birth volumes, with low-risk rural patients having notable discrepancies in SMM risk between low (ARR, 2.32; 95% CI, 1.32-4.07), medium (ARR, 1.66; 95% CI, 1.20-2.28), and medium-high (ARR, 1.68; 95% CI, 1.29-2.18) volume hospitals compared with high volume (>460 births) rural hospitals. Among hospitals in urban counties, there was no significant association between birth volume and SMM for low-risk or higher-risk obstetric patients. Conclusions and Relevance: In this cross-sectional study of births in US rural and urban counties, risk of SMM was elevated for low-risk and higher-risk obstetric patients who gave birth in lower-volume hospitals in rural counties, compared with similar patients who gave birth at rural hospitals with greater than 460 annual births. These findings imply a need for tailored quality improvement strategies for lower volume hospitals in rural communities.