Perinatal care among Hispanic birthing people: Differences by primary language and state policy environment.

OBJECTIVE: The study aims to examine maternal care among Hispanic birthing people by primary language and state policy environment. DATA SOURCES AND STUDY SETTING: Pooled data from 2016 to 2020 Pregnancy Risk Assessment Monitoring System surveys from 44 states and two jurisdictions. STUDY DESIGN: Using multivariable logistic regression, we calculated adjusted predicted probabilities of maternal care utilization (visit attendance, timeliness, adequacy) and quality (receipt of guideline-recommended care components). We examined outcomes by primary language (Spanish, English) and two binary measures of state policy environment: (1) expanded Medicaid eligibility to those <133% Federal Poverty Level, (2) waived five-year waiting period for pregnant immigrants to access Medicaid. DATA COLLECTION/EXTRACTION METHODS: Survey responses from 35,779 postpartum individuals with self-reported Hispanic ethnicity who gave birth during 2016-2020. PRINCIPAL FINDINGS: Compared to English-speaking Hispanic people, Spanish-speaking individuals reported lower preconception care attendance and worse timeliness and adequacy of prenatal care. In states without Medicaid expansion and immigrant Medicaid coverage, Hispanic birthing people had, respectively, 2.3 (95% CI:0.6, 3.9) and 3.1 (95% CI:1.6, 4.6) percentage-point lower postpartum care attendance and 4.2 (95% CI:2.1, 6.3) and 9.2 (95% CI:7.2, 11.2) percentage-point lower prenatal care quality than people in states with these policies. In states with these policies, Spanish-speaking Hispanic people had 3.3 (95% CI:1.3, 5.4) and 3.0 (95% CI:0.9, 5.1) percentage-point lower prenatal care adequacy, but 1.3 (95% CI:-1.1, 3.6) and 2.7 (95% CI:0.2, 5.1) percentage-point higher postpartum care quality than English-speaking Hispanic people. In states without these policies, those same comparisons were 7.3 (95% CI:3.8, 10.8) and 7.9 (95% CI:4.6, 11.1) percentage-points lower and 9.6 (95% CI:5.5, 13.7) and 5.3 (95% CI:1.8, 8.9) percentage-points higher. CONCLUSIONS: Perinatal care utilization and quality vary among Hispanic birthing people by primary language and state policy environment. States with Medicaid expansion and immigrant Medicaid coverage had greater equity between Spanish-speaking and English-speaking Hispanic people in adequate prenatal care and postpartum care quality among those who gave birth.

Health insurance coverage and experiences of intimate partner violence and postpartum abuse screening among rural US residents who gave birth 2016-2020.

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.

Effects of Breastfeeding Peer Counseling on County-Level Breastfeeding Rates Among WIC Participants in Greater Minnesota.

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.

Rural/urban differences in rates and predictors of intimate partner violence and abuse screening among pregnant and postpartum United States residents.

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.

Rural-Urban Differences in Health Care Unaffordability During the Postpartum Period.

OBJECTIVE: The objective of this study was to examine health care unaffordability for rural and urban residents and by postpartum status. METHODS: We used cross-sectional survey data on female-identifying respondents ages 18-44 (n=17,800) from the 2019 to 2021 National Health Interview Study. Outcomes of interest were 3 measures of health care unaffordability. We conducted bivariate and multivariable regression models to assess the association between health care unaffordability, rurality, and postpartum status. RESULTS: Bivariate analyses showed postpartum people reported statistically significantly higher rates of being unable to pay medical bills and having problems medical paying bills, as compared with nonpostpartum people. Rural residents also reported statistically significantly higher rates of being unable to pay their medical bills and having problems paying medical bills as compared with urban residents. In adjusted models, the predicted probability of being unable to pay medical bills among postpartum respondents was 12.8% (CI, 10.1-15.5), which was statistically significantly higher than among nonpostpartum respondents. Similarly, postpartum respondents had statistically significantly higher predicted probabilities of reporting problems paying medical bills (18.4%, CI, 15.4-21.4) as compared with nonpostpartum respondents. The rural residency was not significantly associated with the health care unaffordability outcome measures in adjusted models. CONCLUSIONS: Both postpartum and rural respondents reported higher rates of being unable to pay medical bills and having problems paying medical bills; however, after adjusting for covariates, only postpartum respondents reported statistically significantly higher rates of these outcomes. These results suggest that postpartum status may present challenges to health care affordability that span the urban/rural context.

Rural and Urban Differences in Insurance Coverage at Prepregnancy, Birth, and Postpartum.

OBJECTIVE: To measure insurance coverage at prepregnancy, birth, and postpartum, and insurance coverage continuity across these periods among rural and urban U.S. residents. METHODS: We performed a pooled, cross-sectional analysis of survey data from 154,992 postpartum individuals in 43 states and two jurisdictions that participated in the 2016-2019 PRAMS (Pregnancy Risk Assessment Monitoring System). We calculated unadjusted estimates of insurance coverage (Medicaid, commercial, or uninsured) during three periods (prepregnancy, birth, and postpartum), as well as insurance continuity across these periods among rural and urban U.S. residents. We conducted subgroup analyses to compare uninsurance rates among rural and urban residents by sociodemographic and clinical characteristics. We used logistic regression models to generate adjusted odds ratios (aORs) for each comparison. RESULTS: Rural residents experienced greater odds of uninsurance in each period and continuous uninsurance across all three periods, compared with their urban counterparts. Uninsurance was higher among rural residents compared with urban residents during prepregnancy (15.4% vs 12.1%; aOR 1.19, 95% CI 1.11-1.28], at birth (4.6% vs 2.8%; aOR 1.60, 95% CI 1.41-1.82), and postpartum (12.7% vs 9.8%, aOR 1.27, 95% CI 1.17-1.38]. In each period, rural residents who were non-Hispanic White, married, and with intended pregnancies experienced greater adjusted odds of uninsurance compared with their urban counterparts. Rural-urban differences in uninsurance persisted across both Medicaid expansion and non-expansion states, and among those with varying levels of education and income. Rural inequities in perinatal coverage were experienced by Hispanic, English-speaking, and Indigenous individuals during prepregnancy and at birth. CONCLUSION: Perinatal uninsurance disproportionately affects rural residents, compared with urban residents, in the 43 states examined. Differential insurance coverage may have important implications for addressing rural-urban inequities in maternity care access and maternal health.

Screening for and Experiences of Intimate Partner Violence in the United States Before, During, and After Pregnancy, 2016-2019.

Objectives. To measure rates of intimate partner violence (IPV) screening during the perinatal period among people experiencing physical violence in the United States. Methods. We used 2016-2019 Pregnancy Risk Assessment Monitoring System data (n = 158 338) to describe the incidence of physical IPV before or during pregnancy. We then assessed the prevalence of IPV screening before, during, or after pregnancy and predictors of receiving screening among those reporting violence. Results. Among the 3.5% (n = 6259) of respondents experiencing violence, 58.7%, 26.9%, and 48.3% were not screened before, during, or after pregnancy, respectively. Those reporting Medicaid or no insurance at birth, American Indian/Alaska Native people, and Spanish-speaking Hispanic people faced increased risk of not having a health care visit during which screening might occur. Among those attending a health care visit, privately insured people, rural residents, and non-Hispanic White respondents faced increased risk of not being screened. Conclusions. Among birthing people reporting physical IPV, nearly half were not screened for IPV before or after pregnancy. Public health efforts to improve maternal health must address both access to care and universal screening for IPV. (Am J Public Health. 2023;113(3):297-305. https://doi.org/10.2105/10.2105/AJPH.2022.307195).

Understanding categories of postpartum care use among privately insured patients in the United States: a cluster-analytic approach.

The postpartum period is critical for the health and well-being of birthing people, yet little is known about the range of health care services and supports needed during this time. Maternity care patients are often targeted for clinical interventions based on "low risk" or "high risk" designations, but dichotomized measures can be imprecise and may not reflect meaningful groups for understanding needed postpartum care. Using claims data from privately insured patients with childbirths between 2016 and 2018, this study identifies categories and predictors of postpartum care utilization, including the use of maternal care and other, nonmaternal, care (eg, respiratory, digestive). We then compare identified utilization-based categories with typical high- and low-risk designations. Among 269 992 patients, 5 categories were identified: (1) low use (55% of births); (2) moderate maternal care use, low other care use (25%); (3) moderate maternal, high other (8%); (4) high maternal, moderate other (7%); and (5) high maternal, high other (5%). Utilization-based categories were better at differentiating postpartum care use and were more consistent across patient profiles, compared with high- and low-risk dichotomies. Identifying categories of postpartum care need beyond a simple risk dichotomy is warranted and can assist in maternal health services research, policymaking, and clinical practice.

The time after childbirth is important for the health of a parent who has just given birth, and postpartum experiences and needs vary widely. We studied health care data for privately insured people who gave birth and identified 5 categories of health care use in the postpartum period. None of the categories we uncovered fit the common model of a single visit at 6 weeks postpartum as the sole care needed or used postpartum. Typically, patients are divided into high-risk and low-risk groups, but our research shows that this is insufficient and masks important differences among patients within these dichotomous groups. Using advanced statistical methods to identify categories of health care use after childbirth may improve postpartum health by better targeting resources to those who need them the most.

Association of Health Insurance, Geography, and Race and Ethnicity With Disparities in Receipt of Recommended Postpartum Care in the US.

Importance: 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. Objectives: To examine receipt of recommended postpartum care content and to describe variations across health insurance type, rural or urban residence, and race and ethnicity. Design, Settings, and Participants: 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. Exposures: Medicaid or private health insurance, rural or urban residence, and race and ethnicity (non-Hispanic White or racially minoritized groups). Main Outcomes and Measures: 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. Results: 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%). Conclusions and Relevance: 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.

Rural Hospital Administrators' Beliefs About Safety, Financial Viability, and Community Need for Offering Obstetric Care.

Importance: Rural obstetric unit closures are associated with adverse maternal and infant health outcomes and are most common among low-birth volume facilities located in remote areas. Declining access to obstetric care is a concern in rural communities in the US. Objective: To assess rural hospital administrators' beliefs about safety, financial viability, and community need for offering obstetric care. Design Setting and Participants: Using the American Hospital Association Annual Survey to identify rural hospitals with obstetric units, we developed and conducted a national survey of a sample of rural hospitals that provided obstetric services in 2021. Obstetric unit managers or administrators at 292 rural hospitals providing obstetric services were surveyed from March to August 2021. Exposures: Local factors, clinical safety, workforce, and financial considerations for obstetric services at participating hospitals. Main Outcomes and Measures: Hospital-level decisions on maintaining obstetric care. Results: Of the 93 total responding hospitals (32% response rate), 33 (35.5%) were critical access hospitals, 60 (64.5%) were located in micropolitan rural counties; they had a median (IQR) average daily census of 22 (10-53) patients, and 48 (52.2%) had experienced a recent decline in births, with a median (IQR) of 274 (120-446) births in 2019. Respondents reported that the minimum number of annual births needed to safely provide obstetric care was 200 (IQR, 100-350). From a financial perspective, the minimum number of annual births needed was also 200 (IQR, 120-360). When making decisions about maintaining obstetric care, 51 (64.6%) responding hospitals listed their highest priority as meeting local community needs, 13 (16.5%) listed financial considerations, and 10 (12.7%) listed staffing. Overall, 23 (25%) responding hospitals were not sure they would continue providing obstetrics, or they expected to stop offering this service. Conclusions and Relevance: In this survey of US rural hospitals that offer obstetric services, many administrators indicated prioritizing local community needs for obstetric care over concerns about financial viability and staffing.

Racial/Ethnic Disparities in Postpartum Health Insurance Coverage Among Rural and Urban U.S. Residents.

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 childbirth improves postpartum health-related outcomes, and recent policy efforts focus on extending postpartum Medicaid coverage from 60 days to 1 year postpartum. The purpose of this study is to describe postpartum health insurance coverage for rural and urban U.S. residents who are BIPOC compared to those who are white. Materials and Methods: Using data from the 2016-2019 Pregnancy Risk Assessment Monitoring System (n = 150,273), we describe health insurance coverage categorized as Medicaid, commercial, or uninsured at the time of childbirth and postpartum. We measured continuity of insurance coverage across these periods, focusing on postpartum Medicaid disruptions. Analyses were conducted among white and BIPOC residents from rural and urban U.S. counties. Results: Three-quarters (75.3%) of rural white people and 85.3% of urban white people were continuously insured from childbirth to postpartum, compared to 60.5% of rural BIPOC people and 65.6% of urban BIPOC people. Postpartum insurance disruptions were frequent among people with Medicaid coverage at childbirth, particularly among BIPOC individuals, compared to those with private insurance; 17.0% of rural BIPOC residents had Medicaid at birth and became uninsured postpartum compared with 3.4% of urban white people. Conclusions: Health insurance coverage at childbirth, postpartum, and across these timepoints varies by race/ethnicity and rural compared with urban residents. Policy efforts to extend postpartum Medicaid coverage may reduce inequities at the intersection of racial/ethnic identity and rural geography.

Perinatal outcomes for rural obstetric patients and neonates in rural-located and metropolitan-located hospitals.

OBJECTIVE: To compare rural obstetric patient and neonate characteristics and outcomes by birth location. METHODS: Retrospective observational cohort study of rural residents' hospital births from California, Pennsylvania, and South Carolina. Hospitals in rural counties were rural-located, those in metropolitan counties with ≥10% of obstetric patients from rural communities were rural-serving, metropolitan-located, others were non-rural-serving, metropolitan-located. Any adverse obstetric patient or neonatal outcomes were assessed with logistic regression accounting for patient characteristics, state, year, and hospital. RESULTS: Of 466,896 rural patient births, 64.3% occurred in rural-located, 22.5% in rural-serving, metropolitan-located, and 13.1% in non-rural-serving, metropolitan-located hospitals. The odds of any adverse outcome increased in rural-serving (aOR 1.27, 95% CI 1.10-1.46) and non-rural-serving (aOR 1.35, 95% CI 1.18-1.55) metropolitan-located hospitals. CONCLUSION: One-third of rural obstetric patients received care in metropolitan-located hospitals. These patients have higher comorbidity rates and higher odds of adverse outcomes likely reflecting referral for higher baseline illness severity.

Inequities in Availability of Evidence-Based Birth Supports to Improve Perinatal Health for Socially Vulnerable Rural Residents.

Rural residents in the United States (US) have disproportionately high rates of maternal and infant mortality. Rural residents who are Black, Indigenous, and People of Color (BIPOC) face multiple social risk factors and have some of the worst maternal and infant health outcomes in the U.S. The purpose of this study was to determine the rural availability of evidence-based supports and services that promote maternal and infant health. We developed and conducted a national survey of a sample of rural hospitals. We determined for each responding hospital the county-level scores on the 2018 CDC Social Vulnerability Index (SVI). The sample's (n = 93) median SVI score [IQR] was 0.55 [0.25-0.88]; for majority-BIPOC counties (n = 29) the median SVI score was 0.93 [0.88-0.98] compared with 0.38 [0.19-0.64] for majority-White counties (n = 64). Among counties where responding hospitals were located, 86.2% located in majority-BIPOC counties ranked in the most socially vulnerable quartile of counties nationally (SVI ≥ 0.75), compared with 14.1% of majority-White counties. In analyses adjusted for geography and hospital size, certified lactation support (aOR 0.36, 95% CI 0.13-0.97), midwifery care (aOR 0.35, 95% CI 0.12-0.99), doula support (aOR 0.30, 95% CI 0.11-0.84), postpartum support groups (aOR 0.25, 95% CI 0.09-0.68), and childbirth education classes (aOR 0.08, 95% CI 0.01-0.69) were significantly less available in the most vulnerable counties compared with less vulnerable counties. Residents in the most socially vulnerable rural counties, many of whom are BIPOC and thus at higher risk for poor birth outcomes, are significantly less likely to have access to evidence-based supports for maternal and infant health.

Severe Maternal Morbidity and Mortality Risk at the Intersection of Rurality, Race and Ethnicity, and Medicaid.

OBJECTIVE: We examined differences in rates of severe maternal morbidity and mortality (SMMM) among Medicaid-funded compared with privately insured hospital births through specific additive and intersectional risk by rural or urban geography, race and ethnicity, and clinical factors. METHODS: We used maternal discharge records from childbirth hospitalizations in the Healthcare Cost and Utilization Project's National Inpatient Sample from 2007 to 2015. We calculated predicted probabilities using weighted multivariable logistic regressions to estimate adjusted rates of SMMM, examining differences in rates by payer, rurality, race and ethnicity, and clinical factors. To assess the presence and extent of additive risk by payer, with other risk factors, on rates of SMMM, we estimated the proportion of the combined effect that was due to the interaction. RESULTS: In this analysis of 6,357,796 hospitalizations for childbirth, 2,932,234 were Medicaid funded and 3,425,562 were privately insured. Controlling for sociodemographic and clinical factors, the highest rate of SMMM (224.9 per 10,000 births) occurred among rural Indigenous Medicaid-funded births. Medicaid-funded births among Black rural and urban residents, and among Hispanic urban residents, also experienced elevated rates and significant additive interaction. Thirty-two percent (Bonferroni-adjusted 95% confidence interval, 19%-45%) of SMMM cases among patients with chronic heart disease were due to payer interaction, and 19% (Bonferroni-adjusted 95% confidence interval, 17%-22%) among those with cesarean birth were due to the interaction. CONCLUSIONS: Heightened rates of SMMM among Medicaid-funded births indicate an opportunity for tailored state and federal policy responses to address the particular maternal health challenges faced by Medicaid beneficiaries, including Black, Indigenous, and rural residents.

Association Between Medicaid Expansion And Closure Of Hospital-Based Obstetric Services.

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 obstetric services is that they are frequently unprofitable for hospitals to operate, threatening hospital viability. Medicaid expansion has emerged as a possible remedy for obstetric service closure because it reduces uncompensated care and improves hospital finances. Using national hospital data from the period 2010-18, we assessed the relationship between Medicaid expansion and obstetric service closure in rural and urban communities. We found that expansion led to a large reduction in hospital closures; however, this effect was concentrated among hospitals that did not have obstetric units. Considering closure of obstetric units, we found that rural obstetric units were less likely to close immediately after expansion, but this effect faded within two years. Overall, our findings suggest that Medicaid expansion had little effect on the closure of obstetric services. Policies supporting access to obstetric care may need to directly address the financial challenges specific to this service line.

Birth Volume and Geographic Distribution of US Hospitals With Obstetric Services From 2010 to 2018.

Importance: Timely access to clinically appropriate obstetric services is critical to the provision of high-quality perinatal care. Objective: To examine the geographic distribution, proximity, and urban adjacency of US obstetric hospitals by annual birth volume. Design, Setting, and Participants: 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 & 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. Exposure: Hospital birth volume, defined by annual birth volume categories of 10 to 500, 501 to 1000, 1001 to 2000, and more than 2000 births. Main Outcomes and Measures: 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. Results: 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. Conclusions and Relevance: 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.

Prescription opioid use during pregnancy and risk for preterm birth or term low birthweight.

OBJECTIVE: Examine the relationship between prescription opioid analgesic use during pregnancy and preterm birth or term low birthweight. DESIGN, SETTING, AND PARTICIPANTS: We analyzed data from the National Birth Defects Prevention Study, a US multisite, population-based study, for births from 1997 to 2011. We defined exposure as self-reported prescription opioid use between one month before conception and the end of pregnancy, and we dichotomized opioid use duration by ≤7 days and >7 days. MAIN OUTCOME MEASURES: We examined the association between opioid use and preterm birth (defined as gestational age <37 weeks) and term low birthweight (defined as <2500 g at gestational age ≥37 weeks). RESULTS: Among 10,491 singleton mother/infant pairs, 470 (4.5 percent) reported opioid use. Among women reporting opioid use, 236 (50 percent) used opioids for > 7 days; codeine (170, 36 percent) and hydrocodone (163, 35 percent) were the most commonly reported opioids. Opioid use was associated with slightly increased risk for preterm birth [adjusted odds ratio, 1.4; 95 percent confidence interval, 1.0, 1.9], particularly with hydrocodone [1.6; 1.0, 2.6], meperidine [2.5; 1.2, 5.2], or morphine [3.0; 1.5, 6.1] use for any duration; however, opioid use was not significantly associated with term low birthweight. CONCLUSIONS: Preterm birth occurred more frequently among infants of women reporting prescription opioid use during pregnancy. However, we could not determine if these risks relate to the drug or to indications for use. Patients who use opioids during pregnancy should be counseled by their practitioners about this and other potential risks associated with opioid use in pregnancy.

Local Capacity for Emergency Births in Rural Hospitals Without Obstetrics Services.

BACKGROUND: Rural hospitals are closing obstetric units, and limited information is available about local emergency obstetric preparedness and capacity in rural communities where hospitals do not routinely provide this care. OBJECTIVE: To describe emergency obstetric capacity at rural US hospitals that do not routinely offer childbirth services. METHODS: Data from the 2018 American Hospital Association Annual Survey were used to identify a random sample of rural hospitals that did not offer obstetric services. A survey was developed based on World Health Organization criteria for obstetric emergencies. With data collected from 69 rural hospital emergency departments (48% response rate), we analyzed local capacity to support childbirth. RESULTS: Most responding hospitals (65%) were located 30 or more miles away from a hospital with obstetric services. Some reported having emergency room births in the past year (28%), an unanticipated adverse birth outcome (32%), and/or a delay in urgent transport for a pregnant patient (22%). More than 90% of responding hospitals had capacity for blood transfusion, intravenous antibiotics or anticonvulsants, and basic neonatal resuscitation. However, less than one-fifth had capacity to perform surgery (16%), remove retained products of delivery (17%), or had a policy for emergency cesarean (18%). Almost all respondents (80%) reported the need for additional training or resources to handle emergency obstetric situations. CONCLUSION: Many rural hospitals do not have basic capacity to provide emergency obstetric services. Programs and policies to improve this may focus on surgical care, clinician and staff training, transportation, and coordination with nearby hospitals that provide obstetric services.