Location of childbirth for rural women: implications for maternal levels of care

Abstract

BACKGROUND A recent American College of Obstetricians and Gynecologists and Society for Maternal Fetal Medicine consensus statement on levels of maternity care lays out designations that correspond to specific capacities available in facilities that provide obstetric care. Pregnant women in rural and remote areas receive particular attention in discussions of regionalization and levels of care, owing to the challenges in assuring local access to high-acuity services when necessary. Currently, approximately half a million rural women give birth each year in US hospitals, and whether and which of these women give birth locally is crucial for successfully operationalizing maternal levels of care. OBJECTIVES To characterize rural women who give birth in non-local hospitals and measure local hospital characteristics and maternal diagnoses present at childbirth that are associated with non-local childbirth. STUDY DESIGN This was a repeat cross-sectional analysis of administrative hospital discharge data for all births to rural women in nine states in 2010 and 2012. Multivariate logistic regression models were used to predict the odds of childbirth in a non-local hospital (at least 30 road miles from the patient's residence). We examined patient age, race/ethnicity, payer, rurality, clinical diagnoses (diabetes, hypertension, hemorrhage during pregnancy, placental abnormalities, malpresentation, multiple gestation, preterm delivery, prior cesarean delivery, and a composite of diagnoses that may require maternal-fetal medicine consultation), as well as local hospital characteristics (birth volume, neonatal care level, ownership, accreditation, and system affiliation). RESULTS The rate of non-local childbirth among 216,076 rural women was 25.4%. It varied significantly by primary payer (Adjusted Odds Ratio [95% Confidence Interval]=0.76 [0.68,0.86]) for Medicaid vs. private insurance) and by clinical conditions including multiple gestation (1.82 [1.58,2.1]), preterm deliveries (2.41 [2.17,2.67]), and conditions which may require maternal fetal medicine services or consultation (1.28 [1.22,1.35]). Rural women whose local hospital did not have a neonatal intensive or intermediate care unit had nearly double the odds of giving birth at a non-local hospital (1.94 [1.64,2.31]). CONCLUSION Approximately 75% of rural women gave birth at local hospitals; rural women with preterm births and clinical complications, as well as those without local access to higher-acuity neonatal care, were more likely to give birth in non-local hospitals. However, after controlling for clinical complications, rural Medicaid beneficiaries were less likely to give birth at non-local hospitals, implying a potential access challenge for this population.

The effect of Baby‐friendly status on exclusive breastfeeding in U.S. hospitals

“…This information represents the demographic information for the community surrounding the hospital and provides a proxy for the patients served by the hospital. While many factors influence patients' hospital utilization, studies have shown travel distance is a significant determinant of hospital utilization (Friedman et al, ) and the majority of women deliver at their local hospital (Kozhimannil, Casey, Hung, Prasad, & Moscovice, ). Demographic variables were calculated and expressed as a proportion of the population of interest.…”

Maternal Opioid Use Disorder and Neonatal Abstinence Syndrome Among Rural US Residents, 2007–2014

“…For instance, access to hospital‐based obstetric care is declining in rural United States counties; currently, fewer than half of rural counties have a hospital that provides obstetric services . And, approximately 1 in 4 pregnant rural residents give birth in nonlocal hospitals, often owing to the clinical necessity of higher‐acuity care, which is frequently not available in rural communities . Clinical recommendations for perinatal regionalization support nonlocal childbirth for rural residents with pregnancy complications and those who require higher‐acuity neonatal care .…”

The Impact of Delivery in a Rural County on a Cohort of Women Living with HIV Infection and Their Infants

“…Approximately one‐fourth of American women reside in rural areas and most of these women must drive at least 1 hour to access health care . Women in rural areas experience poorer health outcomes including higher rates of cerebrovascular disease deaths and cervical cancer …”

“…Women residing in rural areas are more likely to initiate prenatal care after the first trimester and may have increased pregnancy complications . Pregnancy complications requiring a higher level of care may require rural women to travel long distances . HIV is considered a high‐risk pregnancy condition, but little information is available regarding pregnancy outcomes among women living with HIV in relation to rural residence…”

“…2 Women in rural areas experience poorer health outcomes including higher rates of cerebrovascular disease deaths and cervical cancer. 2,3 Women residing in rural areas are more likely to initiate prenatal care after the first trimester and may have increased pregnancy complications. 2 Pregnancy compli-cations requiring a higher level of care may require rural women to travel long distances.…”