Identifying Gender-Related Differences in Graduate Medical Education with the Use of a Web-Based Professionalism Monitoring Tool.

OBJECTIVES: Medical education is required to ensure a healthy training and learning environment for resident physicians. Trainees are expected to demonstrate professionalism with patients, faculty, and staff. West Virginia University Graduate Medical Education (GME) initiated a Web-based professionalism and mistreatment form ("button") on our Web site for reporting professionalism breaches, mistreatment, and exemplary behavior events. The purpose of this study was to identify characteristics in resident trainees who had a "button push" activation about their behavior to better understand ways to improve professionalism in GME. METHODS: This West Virginia University institutional review board-approved quality improvement study is a descriptive analysis of GME button push activations from July 2013 through June 2021. We compared characteristics of all of those trainees who had specific button activation(s) about their behavior. Data are reported as frequency and percentage. Nominal data and interval data were analyzed using the χ2 and the t test, respectively. P < 0.05 was significant. Logistic regression was used to analyze those differences that were significant. RESULTS: In the 8-year study period, there were 598 button activations, and 54% (n = 324) of the activations were anonymous. Nearly all of the button reports (n = 586, 98%) were constructively resolved within 14 days. Of the 598 button activations, 95% (n = 569) were identified as involving one sex, with 66.3% (n = 377) identified as men and 33.7% (n = 192) as women. Of the 598 activations, 83.7% (n = 500) involved residents and 16.3% (n = 98) involved attendings. One-time offenders comprised 90% (n = 538), and 10% (n = 60) involved individuals who had previous button pushes about their behavior. CONCLUSIONS: Implementation of a professionalism-monitoring tool, such as our Web-based button push, identified gender differences in the reporting of professionalism breaches, because twice as many men as women were identified as the instigator of a professionalism breech. The tool also facilitated timely interventions and exemplary behavior recognition.

Factors Associated with Acceptance of Repeat MCAT Test Takers into a West Virginian Allopathic Medical School.

OBJECTIVES: A paucity of information exists to advise medical school applicants who have had to retake the Medical College Admission Test (MCAT) to achieve a competitive score. To better advise repeat test takers from West Virginia and other Appalachian and southern areas, MCAT data from West Virginia applicants were analyzed and compared with national data. METHODS: In the application cycles of 2017-2020, the following factors were analyzed in relation to medical school acceptance in West Virginia applicants: MCAT scores, the number of test-taking attempts, biology-chemistry-physics-math grade point average, time between test-taking attempts, and academic major. MCAT data from medical school applicants from West Virginia who took the test more than once also were compared with national data. RESULTS: Of the total repeat test takers from West Virginia (N = 285) in the study timeframe, 57 (20%) were ultimately accepted into medical school. Factors associated with medical school acceptance were as follows: first MCAT test score (odds ratio [OR] 1.3, 95% confidence level [CL] 1.2-1.4, P < 0.001), change in MCAT test score (OR 1.2, 95% CL 1.1-1.3, P = 0.0015), and biology-chemistry-physics-math grade point average (OR 15.1, 95% CL 4.2-54.8, P < 0.0001). The highest benefit for improved scores occurred between the first and second attempts. The highest point gain occurred when the first MCAT score was in the range of 477 to 487 (<1st-12th percentile); this finding was not found in the national data. CONCLUSIONS: Although the study was limited to West Virginia medical school applicants, this information could prove useful in advising premedical applicants from other Appalachian and southern US areas.

Transversus Abdominis Plane Block With Liposomal Bupivacaine for Pain After Cesarean Delivery in a Multicenter, Randomized, Double-Blind, Controlled Trial.

BACKGROUND: In women undergoing cesarean delivery under spinal anesthesia with intrathecal morphine, transversus abdominis plane (TAP) block with bupivacaine hydrochloride (HCl) may not improve postsurgical analgesia. This lack of benefit could be related to the short duration of action of bupivacaine HCl. A retrospective study reported that TAP block with long-acting liposomal bupivacaine (LB) reduced opioid consumption and improved analgesia following cesarean delivery. Therefore, we performed a prospective multicenter, randomized, double-blind trial examining efficacy and safety of TAP block with LB plus bupivacaine HCl versus bupivacaine HCl alone. METHODS: Women (n = 186) with term pregnancies undergoing elective cesarean delivery under spinal anesthesia were randomized (1:1) to TAP block with LB 266 mg plus bupivacaine HCl 50 mg or bupivacaine HCl 50 mg alone. Efficacy was evaluated in a protocol-compliant analysis (PCA) set that was defined a priori. The primary end point was total postsurgical opioid consumption (oral morphine equivalent dosing [MED]) through 72 hours. Pain intensity was measured using a visual analog scale. Adverse events (AEs) after treatment were recorded through day 14. RESULTS: Total opioid consumption through 72 hours was reduced with LB plus bupivacaine HCl versus bupivacaine HCl alone (least squares mean [LSM] [standard error (SE)] MED, 15.5 mg [6.67 mg] vs 32.0 mg [6.25 mg]). This corresponded to an LSM treatment difference of -16.5 mg (95% confidence interval [CI], -30.8 to -2.2 mg; P = .012). The area under the curve of imputed pain intensity scores through 72 hours supported noninferiority of LB plus bupivacaine HCl versus bupivacaine HCl alone (LSM [SE], 147.9 [21.13] vs 178.5 [19.78]; LSM treatment difference, -30.6; 95% CI, -75.9 to 14.7), with a prespecified noninferiority margin of 36 (P = .002). In an analysis of all treated patients, including those not meeting criteria for inclusion in the PCA, there was no difference in postsurgical opioid consumption between groups. In the LB plus bupivacaine HCl group, 63.6% of patients experienced an AE after treatment versus 56.2% in the bupivacaine HCl-alone group. Serious AEs after treatment were rare (≈3% in both groups). CONCLUSIONS: TAP block using LB plus bupivacaine HCl as part of a multimodal analgesia protocol incorporating intrathecal morphine resulted in reduced opioid consumption after cesarean delivery in the PCA set. Results suggest that with correct TAP block placement and adherence to a multimodal postsurgical analgesic regimen, there is an opioid-reducing benefit of adding LB to bupivacaine TAP blocks after cesarean delivery (ClinicalTrials.gov identifier: NCT03176459).

Independent risk factors for surgical site infection after cesarean delivery in a rural tertiary care medical center.

BACKGROUND: We aimed to determine the incidence of surgical site infection (SSI) after cesarean delivery (CD) and identify the risk factors in a rural population. METHODS: We identified 218 SSI patients by International Classification of Disease codes and matched them with 3131 parturients (control) from the electronic record database in a time-matched retrospective quality assurance analysis. RESULTS AND DISCUSSION: The incidence of SSI after CD was 7.0 %. Risk factors included higher body mass index (BMI) [40.30 ± 10.60 kg/m2 SSI (95 % CI 38.73-41.87) vs 34.05 ± 8.24 kg/m2 control (95 % CI 33.75-34.35, P < 0.001)], years of education [13.28 ± 2.44 years SSI (95 % CI 12.9-13.66) vs 14.07 ± 2.81 years control (95 % CI 13.96-14.18, P < 0.001)], number of prior births [2 (1-9) SSI vs 1 (1-11) control (P < 0.001)], tobacco use (OR 1.49; 95 % CI 1.06-2.09, P = 0.03), prior diagnosis of hypertension (OR 1.80; 95 % CI 1.34-2.42, P < 0.001), gestational diabetes (OR 1.59; 95 % CI 1.18-2.13, P = 0.003), and an emergency/STAT CD (OR 1.6; 95 % CI 1.1-2.3, P = 0.01). CONCLUSIONS: Risk factors for SSI after CD included higher BMI, less years of education, higher prior births, tobacco use, prior diagnosis of hypertension, gestational diabetes, and emergency/STAT CD. The presence of ruptured membranes was protective against SSI.

Maternal outcomes in women supplemented with a high-protein drink in labour.

BACKGROUND: Because of the potential aspiration risk, oral intake is restricted during labour. AIMS: To determine whether high-protein drink supplementation in labour decreases nausea and emesis and promotes patient satisfaction. MATERIALS AND METHODS: The study was registered with www.clinicaltrials.gov (NCT01414478). Labouring women were randomised into two groups: Group P received a high-protein drink (325 mL) with ice chips/water PRN; and Group C served as control and received only ice chips/water PRN (Study 1). Incidences of nausea and emesis were measured hourly until delivery and at 1 h postdelivery. Patient satisfaction was measured the following day. A secondary aim was to evaluate the rate of gastric emptying (t½ ) in women who ingested either 325 mL of a high-protein drink or ice chips/water (Study 2) using ultrasound. RESULTS: In Study 1, 150 women were recruited (Group P = 75; Group C = 75). There were no differences in the overall incidences of nausea (P = 0.14), emesis (P = 0.15) or in the incidences at the measured time periods (MANOVA, P > 0.05). Median patient satisfaction scores were higher in Group P than in Group C (P = 0.007). In Study 2, 18 additional patients (Group PG = 9; Group CG = 9) were analysed to determine US gastric emptying t½ rates (PG : 25.56 ± 15.90 min [95% CI: 15.17 - 35.94] compared with CG : 20.00 ± 8.70 min [95% CI: 14.34 - 25.66], P = 0.19). CONCLUSION: In labour, patient satisfaction is improved with high-protein drink supplementation compared with ice chips/water with comparable gastric emptying rates.

Epidural catheter placement in morbidly obese parturients with the use of an epidural depth equation prior to ultrasound visualization.

BACKGROUND: Previously, Balki determined the Pearson correlation coefficient with the use of ultrasound (US) was 0.85 in morbidly obese parturients. We aimed to determine if the use of the epidural depth equation (EDE) in conjunction with US can provide better clinical correlation in estimating the distance from the skin to the epidural space in morbidly obese parturients. METHODS: One hundred sixty morbidly obese (≥40 kg/m(2)) parturients requesting labor epidural analgesia were enrolled. Before epidural catheter placement, EDE was used to estimate depth to the epidural space. This estimation was used to help visualize the epidural space with the transverse and midline longitudinal US views and to measure depth to epidural space. The measured epidural depth was made available to the resident trainee before needle insertion. Actual needle depth (ND) to the epidural space was recorded. RESULTS: Pearson's correlation coefficients comparing actual (ND) versus US estimated depth to the epidural space in the longitudinal median and transverse planes were 0.905 (95% CI: 0.873 to 0.929) and 0.899 (95% CI: 0.865 to 0.925), respectively. CONCLUSION: Use of the epidural depth equation (EDE) in conjunction with the longitudinal and transverse US views results in better clinical correlation than with the use of US alone.

Factors Associated With the Acceptance of Military Applicants to a U.S. Allopathic Medical School.

INTRODUCTION: Service members and veterans applying to medical schools can be a challenging experience. Often, the applicants have difficulty providing descriptions of their experiences. Additionally, their pathway to medical school is significantly different compared to traditional applicants. We sought to determine if there were statistically significant factors within a cohort of U.S. military medical school applications to a U.S.-based allopathic medical school to provide recommendations on how to best advise military applicants. METHODS: Data about social, academic, and military factors were collected and analyzed from the American College Application Service (AMCAS) applications to the West Virginia University School of Medicine (WVU SoM) from the 2017 to 2021 cycles. Eligibility criteria included the applications that indicated that the applicant listed any type of military experience. RESULTS: In the 5-year study period, there were 25,514 applicants to the WVU SoM, and 1.6% (n = 414) self-identified as military applicants. Of the military applicants, 28 (7%) were accepted to the WVU SoM. Statistically significant differences were found in several factors, including but not limited to academic performance, number of total experiences (14.5 vs. 12, P = .01), and number of military experiences (4 vs. 2, P = .003) listed on the AMCAS applications. In the accepted group, 88% of the applications included information about military experiences, which was understandable to the nonmilitary researchers compared to 79% in the nonaccepted group (P = .24). CONCLUSIONS: Premedical advisors can share statistically significant findings with military applicants, so they are informed about the academic and experiential factors associated with medical school acceptance. Applicants should also be advised to provide clear explanations of any military lexicon used in their applications. Although not statistically significant, there were a higher percentage of applications that contained descriptions of military language that was understandable to the civilian researchers in the accepted group vs. the nonaccepted group.

Consensus Practice Guidelines on Postdural Puncture Headache From a Multisociety, International Working Group: A Summary Report.

Importance: Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures, such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis, and management of this condition is, however, currently lacking. Objective: To fill the practice guidelines void and provide comprehensive information and patient-centric recommendations for preventing, diagnosing, and managing PDPH. Evidence Review: With input from committee members and stakeholders of 6 participating professional societies, 10 review questions that were deemed important for the prevention, diagnosis, and management of PDPH were developed. A literature search for each question was performed in MEDLINE on March 2, 2022. Additional relevant clinical trials, systematic reviews, and research studies published through March 2022 were also considered for practice guideline development and shared with collaborator groups. Each group submitted a structured narrative review along with recommendations that were rated according to the US Preventive Services Task Force grading of evidence. Collaborators were asked to vote anonymously on each recommendation using 2 rounds of a modified Delphi approach. Findings: After 2 rounds of electronic voting by a 21-member multidisciplinary collaborator team, 47 recommendations were generated to provide guidance on the risk factors for and the prevention, diagnosis, and management of PDPH, along with ratings for the strength and certainty of evidence. A 90% to 100% consensus was obtained for almost all recommendations. Several recommendations were rated as having moderate to low certainty. Opportunities for future research were identified. Conclusions and Relevance: Results of this consensus statement suggest that current approaches to the treatment and management of PDPH are not uniform due to the paucity of evidence. The practice guidelines, however, provide a framework for individual clinicians to assess PDPH risk, confirm the diagnosis, and adopt a systematic approach to its management.

Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group.

INTRODUCTION: Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH. METHODS: Based on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach. RESULTS: Based on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence. CONCLUSIONS: These clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients' interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.

Maternal and cord serum cytokine changes with continuous and intermittent labor epidural analgesia: a randomized study.

BACKGROUND: Maternal fever during labor epidural analgesia (LEA) may cause increased maternal and cord serum inflammatory cytokines. We report the effects of intermittent and continuous LEA on these cytokines. METHODS: Ninety-two women were randomly assigned to continuous (CLEA) or intermittent (ILEA) groups, 46 in each. Maternal temperature was checked and blood drawn at epidural insertion (baseline) and four-hourly until 4 h postpartum (4 PP). Cord blood was drawn after placental delivery. Interleukin-1ß (IL-1ß), interleukin-6 (IL-6), interleukin-8 (IL-8), granulocyte macrophage-colony stimulating factor (GM-CSF), and tumor necrosis factor-α (TNF-α) were measured and analyzed according to group randomization, and then combined and reanalyzed as febrile (temperature ≥ 38 °C) or afebrile groups. RESULTS: Significant intragroup changes from baseline were noted in some groups. Data are pg/mL, median (Q1/Q3). IL-6 rose at all time points in all groups. CLEA: baseline: 18.5 (12.5/31.1), 4 h: 80.0 (46.3/110.8), 8 h: 171.9 (145.3/234.3), and 4 PP: 81 (55.7/137.4). ILEA: baseline: 15.7 (10.2/27.1), 4 h: 68.2 (33.3/95.0), 8 h: 125.0 (86.3/195.0), and 4 PP: 70.2 (54.8/103.6). Febrile group: baseline: 21.6 (13.8/40.9), 4 h: 83.9 (47.5/120.8), 8 h: 186.7 (149.6/349.9), and 4 PP: 105.8 (65.7/158.8). Afebrile group: baseline: 10.9 (2.1/17.4), 4 h: 38.2 (15.0/68.2), 8 h: 93.8 (57.1/135.7), and 4 PP: 52.9 (25.1/78). IL-8 rose at all time points in CLEA: baseline: 2.68 (0.0/4.3), 4 h: 3.7 (0.0/6.5), 8 h: 6.0 (3.3/9.6), 4 PP: 5.6 (0.8/8.0), and afebrile group baseline: 2.5 (0.0/4.7), 4 h: 3.3 (0.0/6.2), 8 h: 5.3 (1.9/9.8), and 4 PP: 4.7 (0.0/7.6). It fell at 4 PP in febrile group: baseline: 4.1 (0.0/6.4), 4 h: 3.8 (0.0/6.5), 8 h: 5.2 (2.5/8.0), and 4 PP: 2.9 (0.0/4.0). GM-CSF increased at 8 h and decreased at 4 PP in ILEA baseline: 2.73 (0.0/7.2), 4 h: 2.73 (0.0/7.9), 8 h: 3.9 (2.7/11.5), and 4 PP: 2.0 (0.0/7.2). It increased at 4 h and 8 h and decreased at 4 PP in febrile group: baseline: 2.6 (0.0/4.2), 4 h: 3.2 (2.1/7.0), 8 h: 4.0 (3.2/12.3), and 4 PP: 2.4 (1.7/12.6). There were no intergroup cytokine changes in maternal or cord serum in CLEA versus ILEA or febrile versus afebrile groups. CONCLUSIONS: Some cytokines, especially IL-6, rise physiologically during labor epidural analgesia.

Efficacy of the bilateral ilioinguinal-iliohypogastric block with intrathecal morphine for postoperative cesarean delivery analgesia.

The ilioinguinal-iliohypogastric (IIIH) block is frequently used as multimodal analgesia for lower abdominal surgeries. The aim of this study is to compare the efficacy of IIIH block using ultrasound visualization for reducing postoperative pain after caesarean delivery (CD) in patients receiving intrathecal morphine (ITM) under spinal anesthesia. Participants were randomly assigned to 1 of 3 treatment groups for the bilateral IIIH block: Group A = 10 mL of 0.5% bupivacaine, Group B = 10 mL of 0.5% bupivacaine on one side and 10 mL of a normal saline (NSS) placebo block on the opposite side, and Group C = 10 mL of NSS placebo per side. Pain and nausea scores, treatment for pain and nausea, and patient satisfaction were recorded for 48 hours after CD. No differences were noted with respect to pain scores or treatment for pain over the 48 hours. There were no differences to the presence of nausea (P = 0.64), treatment for nausea (P = 0.21), pruritus (P = 0.39), emesis (P = 0.35), or patient satisfaction (P = 0.29). There were no differences in pain and nausea scores over the measured time periods (MANOVA, P > 0.05). In parturients receiving ITM for elective CD, IIIH block offers no additional postoperative benefit for up to 48 hours.

Post-dural puncture headache diagnosis and management.

Epidural analgesia, commonly used to alleviate labor pain, is not without complication. The most common complication associated with labor epidural analgesia (LEA) is Unintentional Dural Puncture (UDP), where many professionals go on to develop a Post Dural Puncture Headache (PDPH). Spinal anesthesia can also result in PDPH. Other complications of dural puncture necessitating further treatment include hospital readmission, persistent headache, persistent backache, cerebral venous thrombosis, subdural hematoma, postpartum depression, post-traumatic stress disorder, and decreased maternal breastfeeding. In this article, we will define and discuss the definition and diagnosis for PDPH, the pathophysiology of PDPH, PDPH treatment options including conservative therapy, pharmacologic therapy, and invasive procedural measures including the therapeutic epidural blood patch, prophylactic epidural blood patch, intrathecal catheter placement after UDP, and potential new therapies.

Virtual interviewing in the COVID-19 era: A survey of graduate program directors.

PURPOSE/OBJECTIVE: Due to the coronavirus pandemic, virtual interviews became a mainstay of graduate dental and medical education selection processes. To gain a handle on how to navigate lingering uncertainties about how interviews should be conducted in the future, this study examined the benefits and pitfalls of the virtual interview process (VIP) and assessed program plans to implement in the next interview cycle. METHODS: An anonymous online survey, for completion by one program representative (director or associate director), was sent to graduate medical education (GME) and advanced dental education programs at West Virginia University (N = 74). RESULTS: Fifty-two (52) of the programs (70%) completed the survey. Zoom was the most frequently used interview platform (78.8%). Approximately two thirds (65.4%) of the interviewers thought VIP allowed the program to promote the university, the school, and their program and also reported experiencing video-conferencing fatigue. About six in 10 perceive VIP can introduce bias in selecting applicants (59.6%) and potentially disadvantage some applicants (67.3%). Compared to the previous in-person cycle, 67.4% of programs invited more applicants, and 73.1% interviewed more applicants. Regarding the 2021-2022 interview cycle, 55.8% of programs plan to offer either an in-person or VIP, while 7.7% plan to keep their process completely virtual. CONCLUSION: Graduate programs in this study demonstrated the indispensability of technology in transitioning from in-person to virtual interviews during COVID-19 pandemic. VIP has several advantages and disadvantages; this style of interview is forecasted to have a presence in applicant selection in the future.

A Comparative Study of Braided versus Barbed Suture for Cystotomy Repair.

BACKGROUND: In this study, we aim to compare outcomes after cystotomy repair between standard sutures (910 polyglactin, poliglecaprone) versus barbed (V-LocTM 90) suture. As a secondary outcome, we analyzed factors for suture preference between the two groups. METHODS: A retrospective chart review was undertaken for surgeries complicated by cystotomy, identified by ICD-9/10 codes from 2016 to 2019 at West Virginia University (WVU) Hospital. Comparisons were made between cystotomy repair using barbed suture versus standard braided suture. Injuries were categorized by procedure, surgical route, type of suture used in repair, and subsequent complications related to repair. Primary endpoints were examined by Pearson's Chi-square test and interval data by t-test. A p < 0.05 was significant. RESULTS: Sixty-eight patients were identified with iatrogenic cystotomy at WVU. Barbed suture was used for cystotomy repair in 11/68 (16.2%) patients. No significant difference was seen in postoperative outcomes between patients repaired with barbed suture versus standard braided suture. Barbed suture was significantly more likely to be used for cystotomy repair in minimally invasive surgery (p = 0.001). It was most often utilized in a robotic approach 7/11 (63.6%) followed by laparoscopic 3/11 (27.3%). Body mass index (BMI) was significantly higher in patients receiving a barbed suture repair (p = 0.005). CONCLUSION: Barbed suture may be comparable to standard braided suture for cystotomy repair. Barbed suture may offer a practical alternative to facilitate cystotomy repair in minimally invasive surgery, especially in patients with a high BMI.

The influence of medical insurance on obstetrical care.

Maternal and obstetrical outcomes vary widely within the United States. The impact of insurance type on health care disparities and its influence on obstetrical care and maternal outcome is not clear. We report the impact of health care insurance on obstetrical and maternal outcomes in a tertiary care health care system. Our maternal quality care database (n = 4199) was queried comparing commercial insurance to government sponsored insurance from July 1, 2015 through June 30, 2018. Parturients with commercial insurance were older, weighed more, presented with less gravidity and parity, had more advanced gestation, and had a higher neonatal 5-minute Apgar score than government insured parturients. Additionally, government insured parturients were less likely to be admitted for induction with oxytocin, receive labor epidural analgesia, and have a primary caesarean delivery. Similarly, government insured parturients were more likely to be of African American descent, be a current known smoker, have a positive urine drug screen, and receive a general anesthetic. We conclude obstetrical and maternal health care disparities exist based on medical insurance type.