Association of prenatal stress with distance to delivery for pregnant women in Western North Carolina.

PURPOSE: Rural areas throughout the US continue to see closures of maternity wards and decreasing access to prenatal and intrapartum care. Studies examining closure's impacts have demonstrated both positive and negative effects on maternal and neonatal outcomes of mortality and morbidity. Our study aims to build on growing evidence from Canada and Scandinavia that suggests increased travel time to give birth is associated with increased emotional and financial stress for rural pregnant women. METHODS: Pregnant patients at 7 clinic sites in western North Carolina were invited to complete the Rural Pregnancy Experience Scale (RPES) while waiting for their prenatal appointments. Results were analyzed using adjusted linear regressions to examine the correlation between RPES scores and self-reported distance to anticipated birth location as well as RPES scores with recent local labor and delivery closure. FINDINGS: A total of 174 participants completed the survey and met inclusion criteria. For every 10 min increase in travel distance to the patient's anticipated place of delivery, RPES scores increased by an average of 0.72 points. Participants who reported a recent labor and delivery unit closure near them saw average increases of 2.52 on the RPES. CONCLUSIONS: Our findings are consistent with the growing body of literature internationally that demonstrates the distance required to travel to delivery location is associated with increased stress among rural pregnant women.

Exploration of the Effects of Rural Obstetric Unit Closures on Birth Outcomes in North Carolina.

PURPOSE: Closures of rural labor and delivery (L/D) units have prompted national and state-based efforts to assess the impact on birth outcomes. This study explores local effects of L/D closures in rural areas of North Carolina (NC). METHODS: This is a retrospective cohort study of birth outcomes of 4,065 women in 5 rural areas of NC with L/D unit closures between 2013 and 2017. Outcomes were abstracted from birth certificate data from the NC Vital Statistics Reporting System. Localized outcomes 1 year prior to L/D unit closure were compared with outcomes 1 and 2 years post closure, including: (1) birth location and demographics, (2) change in travel patterns for birth, and (3) birth outcomes, including rates of labor induction, cesarean deliveries, maternal morbidity, and neonatal outcomes. FINDINGS: Before closures, 25%-56% of deliveries occurred outside county of residence. Commercially insured and college-educated women were more likely to deliver out-of-area. Closures increased travel distance to delivery hospital an average of 7-27 miles. In 2 areas, cesarean delivery rates decreased despite an increase in labor inductions. There was also variability between areas in prenatal care adequacy and breastfeeding. CONCLUSIONS: We found that L/D unit closures in rural NC disproportionately affected women on Medicaid. The impact showed area-specific variability, highlighting effects potentially masked by statewide or national analyses. Implications for future L/D closures would be eased by regional coordination and planning to mitigate negative effects, and state and national policies should address the excess burden placed on vulnerable populations.

A Cohort Comparison of Differences Between Regional and Buncombe County Patients of a Comprehensive Perinatal Substance Use Disorders Program in Western North Carolina.

BACKGROUND Pregnant patients from rural counties of Western North Carolina face additional barriers when accessing comprehensive perinatal substance use disorders care at Project CARA as compared to patients local to the program in Buncombe County. We hypothesized regional patients would be less engaged in care.METHOD Using a retrospective cohort design, univariate analyses (χ2, t-test; P < .05) compared patients' characteristics, engagement in care, and delivery outcomes. Engagement in care, the primary outcome, was operationalized as: attendance at expected, program-specific prenatal and postpartum visits, utilization of in-house counseling, community-based and/or inpatient substance use disorders treatment, and maternal urine drug screen at delivery negative for illicit substances.RESULTS Regional patients (n = 324) were more likely than Buncombe County patients (n = 284) to have opioid [209 (64.5%) versus 162 (57.0%)] or amphetamine/methamphetamine use disorders (25 [7.7%] versus 13 [4.6%]), but less likely to have cannabis use (19 [5.9%] versus 38 [13.4%]; P = .009) and concurrent psychiatric disorders (214 [66.0%] versus 220 [77.5%]; P = .002). Engagement at postpartum visits was the significantly different outcome between patients (110/221 [49.8%] versus 146/226 [64.6%]; P = .002).LIMITATIONS Outcomes were available for 66.8% of regional and 79.6% of Buncombe County patients of one program in one predominately white, non-Hispanic region of the state.CONCLUSION Contrary to our hypothesis, regional and Buncombe County women engaged in prenatal care equally. However, a more formal transition into the postpartum period is needed, especially for regional women. A "hub-and-spokes" model that extends delivery of perinatal substance use disorders care into rural communities may be more effective for engagement retention.