Rural-Urban Differences in Maternal Mortality Trends in the United States, 1999-2017: Accounting for the Impact of the Pregnancy Status Checkbox.

It has been difficult to measure rural-urban differences in maternal mortality ratios (MMRs) in the United States in recent years because of the incremental adoption of a pregnancy status checkbox on the standard US death certificate. Using 1999-2017 mortality and birth data, we examined the impact of the pregnancy checkbox on MMRs according to urbanicity of residence (large urban area, medium/small urban area, or rural area), using log-binomial regression models to predict trends that would have been observed if all states had adopted the checkbox as of 1999. Implementation of the checkbox resulted in an average estimated increase of 7.5 maternal deaths per 100,000 live births (95% confidence interval (CI): 6.3, 8.8) in large urban areas (a 76% increase), 11.6 (95% CI: 9.6, 13.6) in medium/small urban areas (a 113% increase), and 16.6 (95% CI: 12.9, 20.3) in rural areas (a 107% increase), compared with MMRs prior to the checkbox. Assuming that all states had the checkbox as of 1999, demographic-factor-adjusted predicted MMRs increased in rural areas, declined in large urban areas, and did not change in medium/small urban areas. However, trends and urban-rural differences were substantially attenuated when analyses were limited to direct/specific causes of maternal death, which are probably subject to less misclassification. Accurate ascertainment of maternal deaths, particularly in rural areas, is important for reducing disparities in maternal mortality.

Evaluation of the Pregnancy Status Checkbox on the Identification of Maternal Deaths.

Objectives-This report quantifies the impact of the inclusion of a pregnancy status checkbox item on the U.S. Standard Certificate of Death on the number of deaths classified as maternal. Maternal mortality rates calculated with and without using the checkbox information for deaths in 2015 and 2016 are presented. Methods-This report is based on cause-of-death information from 2015 and 2016 death certificates collected through the National Vital Statistics System. Records originally assigned to a specified range of ICD-10 codes (i.e., A34, O00-O99) when using information from the checkbox item were recoded without using the checkbox item. Ratios of deaths assigned as maternal deaths using checkbox item information to deaths assigned without checkbox item information were calculated to quantify the impact of the pregnancy status checkbox item on the classification of maternal deaths for 47 states and the District of Columbia. Maternal mortality rates for all jurisdictions calculated using cause-of-death information entered on the certificate with and without the checkbox were compared overall and by characteristics of the decedent. Results-Use of information from the checkbox, along with information from the cause-of-death section of the certificate, identified 1,527 deaths as maternal compared with 498 without the checkbox in 2015 and 2016 (ratio = 3.07), with the impact varying by characteristics of the decedent such as age at death. The ratio for women under age 25 was 2.15 (204 compared with 95 deaths) but was 14.14 (523 compared with 37 deaths) for women aged 40-54. Without the adoption of the checkbox item, maternal mortality rates in both 2015 and 2016 would have been reported as 8.7 deaths per 100,000 live births compared with 8.9 in 2002. With the checkbox, the maternal mortality rate would be reported as 20.9 and 21.8 deaths per 100,000 live births in 2015 and 2016.

National trends in primary cesarean delivery, labor attempts, and labor success, 1990-2010.

OBJECTIVE: The national primary cesarean delivery rate increased until 2004, but after 2004, this rate cannot be tracked using Vital Statistics data. Additionally, it is unknown whether changes in the primary cesarean delivery rate reflect changes in the rate of labor attempts, labor success, or both. Here, using hospital discharge data, we examined national trends in primary cesarean deliveries, labor attempts, and labor success among women without prior cesarean delivery between 1990 and 2010. STUDY DESIGN: This analysis of serial cross-sectional data from the National Hospital Discharge Survey used Joinpoint regression to assess trends over time and logistic regression with marginal effects to identify rates of change over time and adjust for demographic and clinical factors. RESULTS: The primary cesarean delivery rate declined 0.2 percentage points per year (95% confidence interval [CI], 0.1-0.3) between 1990 and 1999, increased 1.0 percentage point per year (95% CI, 0.8-1.2) between 1999 and 2004, and increased 0.3 percentage points (95% CI, 0.1-0.6) per year from 2004 until 2010. Between 1998 and 2005, the rate of labor attempts declined 0.4 percentage points (95% CI, 0.3-0.5) per year. No changes in the labor attempt rate occurred between 2005 and 2010. Labor success rates increased 0.2 percentage points (95% CI, 0.1-0.3) per year between 1990 and 1998 but then declined 0.5 (95% CI, 0.5-0.8) percentage points per year from 1998 to 2010. Adjusted results were similar. CONCLUSION: The primary cesarean delivery rate continued to increase after 2004. Increases in the primary cesarean delivery rate after 2005 were driven by declines in labor success rates.

Rates and success rates of trial of labor after cesarean delivery in the United States, 1990-2009.

This study compares rates of trial of labor after Cesarean delivery (TOLAC) and rates of successful TOLAC between 1990 and 2009. Serial cross-sectional analyses were performed using the National Hospital Discharge Survey data to compare rates of TOLAC and TOLAC success between 1990 and 2009. Joinpoint regression was used to assess trends over time, and logistic regression with marginal effects was used to examine the unadjusted and adjusted significance and magnitude of trends. The rate of TOLAC reached a high of 51.8 % (95 % CI 47.8-55.8 %) in 1995 and a low of 15.9 % (95 % CI 13.8-18.0 %) in 2006, declined, on average, 4.2 (95 % CI -4.8 to -3.9) percentage points per year between 1996 and 2005. Rates increased significantly from 1990 to 1996 and 2005 to 2009. TOLAC success was at its highest rate in 2000, 69.8 % (95 % CI 65.2-74.3 %) and its lowest in 2008, 38.5 % (95 % CI 28.1-48.8 %). The rate of TOLAC success increased significantly between 1990 and 2000, but declined thereafter an average of 3.4 % points per year (95 % CI -4.3 to -2.5). The rate of TOLAC in the US decreased between 1996 and 2005 and the rate of successful TOLAC has declined from 2000 to 2009.

The Impact of the Pregnancy Checkbox and Misclassification on Maternal Mortality Trends in the United States, 1999-2017.

Maternal mortality is a critical indicator of population health in both the United States and internationally (1-3). Monitoring maternal mortality over time is important to evaluate progress in improving maternal health in the United States, to make international comparisons, and to examine differences and inequities by demographic subgroup (3). Substantial disparities in maternal mortality exist by race and Hispanic origin and age in the United States (4-6). Maternal and pregnancy-related mortality rates for non-Hispanic black women are approximately three times the rates for non-Hispanic white women, while women aged 40 and over have the highest maternal mortality rates compared with other age groups (4,6,7).

Emergency preparedness: addressing a residency training gap.

As the importance of physician involvement and leadership in crisis preparedness is recognized, the literature suggests that few physicians are adequately trained to practice effectively in a large-scale crisis situation. A logical method for addressing the emergency preparedness training deficiency identified across several medical specialties is to include disaster and emergency preparedness training in residency curricula. In this article, the authors outline the development and implementation of an emergency preparedness curriculum for the Johns Hopkins General Preventive Medicine Residency (JHGPMR) from 2004 to 2006. The curriculum consists of two components. The first was developed for the academic year in the JHGPMR and includes didactic lectures, practical exercises to apply new knowledge, and an opportunity to integrate the knowledge and skills in a real-world exercise. The second, developed for the practicum year of the residency, includes Web-based lectures and online content and culminates in a tabletop preparedness exercise. Topics for both components include weapons of mass destruction, risk communication and personal preparedness, aspects of local emergency response planning, and mental health and psychological aspects of terrorism. On the basis of the emergency preparedness training gap that has been identified in the literature, and the success of the three-year experience in implementing a preparedness training curriculum in the JHGPMR, the authors recommend incorporation of competency-based emergency preparedness training for residencies of all specialties, and offer insights into how the described curriculum could be adapted for use in other residency settings.

Sports Team Participation Among US High School Girls, 1999-2015.

Sports team participation has myriad benefits for girls. We used the 1999-2015 Youth Risk Behavior Survey, a nationally representative survey of US high school students, to examine time trends in sports team participation. Data from 2015 alone were examined for current differences in participation by sex, race/ethnicity, grade, and weight status. For both analyses, unadjusted and adjusted logistic regressions, with team participation as the dependent variable, were used. In 2015, 53% of US high school girls participated in team sports. Participation was higher among non-Hispanic white (60.7%) compared to Hispanic (40.7%) and Asian (35.6%) girls, and girls with normal-weight status (58.1%) compared to overweight (50.0%) and obese (36.5%) girls ( P < .01 for all comparisons). From 1999 to 2015, the rate of increase in participation was higher among non-Hispanic black girls than non-Hispanic white girls. No increase was observed for Hispanic and Asian girls. Addressing the disparities found in team participation is imperative.

Trends in Seeing an Obstetrician-Gynecologist Compared With a General Physician Among U.S. Women, 2000-2015.

OBJECTIVE: To assess trends in the percentage of U.S. women who visit an obstetrician-gynecologist (ob-gyn) and the percentage who visit a general physician (general practitioner, family medicine, and internist). METHODS: We used data from the 2000-2015 National Health Interview Surveys, cross-sectional nationally representative surveys, to identify the percentage of U.S. women who have visited an ob-gyn and the percentage who have visited a general physician during the preceding 12 months. Unadjusted percentages, and percentages adjusted for sociodemographic and health factors, were entered into joinpoint regressions to assess unadjusted and adjusted trends over time. RESULTS: The adjusted percentage of U.S. women who saw a general physician during the preceding 12 months did not significantly change from 2000 to 2015, ranging from 70.1% in 2007 to 74.2% in 2003 (P>.05 for trend). However, although the adjusted percentage that saw an ob-gyn in the preceding 12 months did not change from 2000 to 2003 or 2007-2011 (P>.05), it declined from 45.0% to 41.2% between 2003 and 2007 and from 41.8% to 38.4% between 2011 and 2015 (P<.001 for trends). The adjusted percentage that saw both an ob-gyn and a general physician was 32.4% in 2000, reaching as high as 35.2% in 2003, but then declined to 29.8% in 2015 (P<.001 for trend). Unadjusted results were similar. CONCLUSION: The percentage of women who visit an ob-gyn has declined since 2000. To assure high-quality and coordinated care, physicians should identify whether women see both health care provider types or only one to help assure that all recommended services are being offered.

Physician Office Visits by Children for Well and Problem-focused Care: United States, 2012.

KEY FINDINGS: Data from the National Ambulatory Medical Care Survey, 2012 •Physician office visit rates for well care were lower for school-aged (those aged 6-11 years) children (31 per 100 population) and adolescents aged 12-17 years (29 per 100 population) than for younger children (349 and 74 per 100 population for children under age 1 year and 1-5 years, respectively). •Visit rates for well and problem-focused care were highest for general pediatricians (59 and 173 per 100 population) compared with other primary (7 and 25 per 100 population) and specialty care providers (1 and 24 per 100 population) across all age groups. •Among school-aged and adolescent children, a higher percentage of well-care visits had recommended height, weight, and blood pressure measurements recorded, compared with visits for problem-focused care.

Trends in emergency department visits for ischemic stroke and transient ischemic attack: United States, 2001-2011.

Stroke is the fifth leading cause of death in the United States. About 87% of all strokes are ischemic strokes. Transient ischemic attacks (TIAs) cause similar symptoms, but the blockage of blood flow to the brain is temporary. However, about one-third of people who have a TIA will have a stroke within 1 year (3). Emergency departments play a critical role in the diagnosis and management of ischemic stroke and TIA. The evaluation of these conditions in the emergency department is similar, so they are combined for this analysis. This report presents recent trends in visits to emergency departments for ischemic stroke or TIA.

Emergency department visits for drug poisoning: United States, 2008-2011.

Poisoning is the leading cause of injury-related mortality in the United States, with more than 40,000 deaths annually. Drugs account for 90% of poisoning deaths, and the number of deaths from drug poisoning has increased substantially in recent years. The emergency department (ED) plays an important role in the treatment of poisoning. This report describes nationally representative data on ED visits for drug poisoning during 2008-2011.

Maternal Morbidity for Vaginal and Cesarean Deliveries, According to Previous Cesarean History: New Data From the Birth Certificate, 2013.

This report presents recent findings for 2013 on four maternal morbidities associated with labor and delivery-maternal transfusion, ruptured uterus, unplanned hysterectomy, and intensive care unit (ICU) admission-that are collected on birth certificates for a 41-state and District of Columbia reporting area, which represents 90% of all births in the United States.

Routine prenatal care visits by provider specialty in the United States, 2009-2010.

KEY FINDINGS: Data from the 2009 and 2010 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey •At 14.1% of routine prenatal care visits in the United States in 2009-2010, women saw providers whose specialty was not obstetrics and gynecology (ob/gyn). •The percentage of routine prenatal care visits that were made to non-ob/gyn providers was highest (20.5%) among women aged 15-19. •Visits to non-ob/gyn providers accounted for a higher percentage of routine prenatal care visits among women with Medicaid (24.3%) and women with no insurance (23.1%) compared with women with private insurance (7.3%). •The percentage of routine prenatal care visits to non-ob/gyn providers was lower among women in large suburban areas (5.1%) compared with those in urban areas (14.4%) or in small towns or suburbs (22.4%). Early and adequate prenatal care is a Healthy People 2020 objective (1). Previous studies have focused on practice patterns of obstetricians/gynecologists or overall ambulatory care utilization by women (2-5). However, the amount of routine prenatal care delivered by obstetrics and gynecology (ob/gyn) providers and non-ob/gyn providers has not been quantified. Understanding which providers deliver prenatal care may yield valuable information about training and workforce needs. This report quantifies the amount of routine prenatal care delivered by non-ob/gyn providers among women aged 15-54 who were seen in physicians' offices, community health centers, and hospital outpatient departments (OPDs).

Source of payment for the delivery: births in a 33-state and District of Columbia reporting area, 2010.

OBJECTIVES: This report presents new data from birth certificates on the principal source of payment for the delivery in 2010 for the following groups: private insurance, Medicaid, self-pay (uninsured), and other payment sources. These data are for the 33 states and District of Columbia that adopted the 2003 U.S. Standard Certificate of Live Birth by January 2010, representing 76% of all 2010 U.S. births. Trend data for the United States for 1990-2010 are also presented from the Centers for Disease Control and Prevention's National Center for Health Statistics, National Hospital Discharge Survey (NHDS), to provide a national comparison and historical context. METHODS: Tabular and graphical data on deliveries by the principal source of payment for 2010 from the birth certificate are compared with NHDS estimates. Trend data for 1990-2010 from NHDS are also presented. Detailed data from the birth certificate on maternal characteristics, prenatal care receipt, and cesarean delivery are provided. RESULTS: Private insurance was the most frequent payment source for deliveries in the birth certificate-revised reporting area in 2010 (45.8% of births), followed closely by Medicaid (44.9%), ''other'' payment sources (5.0%), and self-pay (4.4%). Similarly, NHDS data show that private insurance was the most common payment source for deliveries nationally in 2010, followed by Medicaid. Privately insured deliveries declined over the last decade, while the use of Medicaid insurance increased. Medicaid insurance of deliveries was highest for births to teenagers and for non-Hispanic black and Hispanic mothers, according to the birth certificate data. Privately insured mothers were most likely of all payment groups to receive early prenatal care and to have cesarean deliveries.

Provider attitudes toward clinical protocols in obstetrics.

The Johns Hopkins Oxytocin Protocol (JHOP) Survey was distributed to clinical labor and delivery staff to compare obstetrical providers' attitudes toward clinical protocols and the JHOP. Agreement by registered nurses (RNs), physicians in training (PIT), and attending physicians (APs) and certified nurse midwives (CNMs) was assessed with each of 4 attitudinal statements regarding whether clinical protocol and JHOP use result in better practice and are important to ensure patient safety. Odds of agreement with positive statements regarding clinical protocols did not differ significantly among groups. Odds of agreement with JHOP use resulting in better practice also did not differ significantly among provider groups. Odds of agreement with the JHOP being important to ensure patient safety were lower for the AP/CNM group compared with the RN group. Clinical protocol use is generally well received by obstetrical providers; however, differences exist in provider attitudes toward the use of an institutional oxytocin protocol.

Physician assistant and advance practice nurse care in hospital outpatient departments: United States, 2008-2009.

This analysis shows that visits to PAs or APNs have become more common in hospital OPDs over the past decade. Several of the 2008­2009 findings are consistent with previous studies. For example, visits seen only by a PA or APN continue to be higher in rural areas. In addition, a higher proportion of visits to PAs or APNs occur with younger patients. This analysis uncovered some new findings about PAs or APNs in hospital OPDs. Visits to PAs or APNs are more common in nonteaching hospitals and in smaller hospitals. General medical and obstetrics or gynecology clinics have higher percentages of PA or APN visits than either pediatric or surgery clinics. PAs or APNs in hospital OPDs provide services to patients for whom the clinic serves as a primary care provider and for assessing new problems or provision of preventive care. PAs or APNs are providing an increasing share of care delivered in OPDs compared with the previous decade. The findings in this report suggest that PAs or APNs continue to provide a critical health care function by providing care in settings with fewer physicians, such as rural locations, small hospitals, and nonteaching hospitals.

Visits to primary care delivery sites: United States, 2008.

This study describes primary care delivery across ambulatory care settings. Although the majority of visits to primary care settings occur in physician offices (84%), OPDs and CHCs are important sources of primary care for poor and uninsured populations. CHCs also had a higher percentage of visits by patients with one or more chronic conditions compared with office-based physicians and OPDs. This higher burden may not be surprising, as there are well-established associations between socioeconomic status and health. Although OPDs and CHCs serve patients from similar neighborhoods and with similar sources of payment, OPDs receive fewer visits by patients with chronic disease. These observations may reflect true differences in case mix or differences in awareness or documentation of chronic disease across settings. The higher percentage of hospital OPD visits in which imaging and nonmedication treatment was ordered or provided compared with physician offices and CHCs may be due to greater access to these services in a hospital setting. Additionally, our analysis suggests OPDs serve a critical complementary function to CHCs by providing care for acute conditions. These findings are consistent with the role of CHCs and OPDs in the health care safety net.

A national analysis of the relationship between hospital volume, academic center status, and surgical outcomes for abdominal hysterectomy done for leiomyoma.

BACKGROUND: Volume-to-outcomes relationships have been established for high-risk surgical procedures. To determine whether hospital volume and academic center status affect surgical outcomes in a lower-risk procedure, morbidity and mortality in patients undergoing abdominal hysterectomy for leiomyoma were evaluated. STUDY DESIGN: Administrative data from the National Inpatient Sample were used to conduct a retrospective analysis of 172,344 individuals who had primary diagnoses of leiomyomata (ICD-9 diagnosis codes of 218.x in the first 2 positions) and who underwent abdominal hysterectomy (ICD-9 procedure codes 68.4 in the first 2 positions) from 1999 to 2003. Comparison was made between teaching hospitals versus nonteaching hospitals and annual case volume in quintiles. Morbidity was considered to be any postoperative condition that is not an expected outcome of hysterectomy and defined as instances in which a patient suffered hemorrhage, ureteral injury, bladder injury, intestinal injury, wound dehiscence, wound infection, deep vein thrombosis, pulmonary embolism, or required blood transfusion. RESULTS: A total of 37 deaths were observed. Mortality was not significantly related to hospital volume or academic medical center status. In contrast, morbidity was found to have a positive association with academic medical center status (odds ratio = 1.34; 95% CI, 1.23 to 1.45), although an inverse relationship between volume and morbidity was observed for extended length of stay (> 3 days) and blood transfusion outcomes in the first 3 (lowest) volume quintiles and for pulmonary embolism in the highest-volume quintile. No important association with volume was found for hemorrhage, ureteral injury, bladder injury, or intestinal injury. CONCLUSIONS: Unlike high-risk procedures, such as esophagectomy, pediatric cardiac surgery, and pancreaticoduodenectomy, mortality for abdominal hysterectomy done for benign indication does not improve with hospital volume or academic center status. The statistically significant positive association between academic medical center status and morbidity merits additional characterization to target areas for improvement.