Trends in Rural and Urban Deliveries and Vaginal Births: California 1998‐2002

Hughes, Susan M.; Zweifler, John; Garza, Alvaro; Stanich, Matthew A.

doi:10.1111/j.1748-0361.2008.00189.x

Cited by 10 publications

(6 citation statements)

References 14 publications

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“…Rural regions of the state are served by fewer labor and delivery (L&D) units located in expansive and sparsely-populated regions, so regionalization of births occurring in these hospitals is less feasible, and standards of volume likely differ in rural regions. 21 There is no universally agreed-upon definition of rural, 22 so we employed a system relying on multiple sources, designating maternity hospitals as rural if they met one of the following criteria: hospitals designated as rural by the California OSHPD, 23 hospitals in towns with a California Association of Rural Health Clinics member clinic, 24 and hospitals located in rural ZIP codes according to the Rural-Urban Commuting Area (RUCA) codes (RUCA-2 codes 4 – 10). 22, 25 After preliminary analysis indicated that rural hospitals should be analyzed separately, we devised three obstetric volume categories for rural hospitals, dividing the hospitals approximately into tertiles by volume: 50 – 599 deliveries (Category R1), 600 – 1,699 deliveries (R2), and 1,700 deliveries or greater (R3).…”

Section: Methodsmentioning

confidence: 99%

“…If it would be logistically feasible for the women served by these hospitals to be referred to nearby higher-volume hospitals, then it might be advisable to concentrate low-risk maternity services in urban, high-obstetric-density areas. However, given the increasing scarcity of obstetrical care in rural regions of the West, 20, 21, 26 the finding of increased risk at lower rural hospital volume will likely need different policy approaches to achieve improvement.…”

Section: Commentmentioning

confidence: 99%

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The association between hospital obstetric volume and perinatal outcomes in California

Snowden

Cheng

Kontgis

et al. 2012

American Journal of Obstetrics and Gynecology

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Objective To analyze the association between hospital obstetric volume and perinatal outcomes in California. Study Design This was a retrospective cohort study of births occurring in California in 2006. Hospitals were divided into four obstetric volume categories. Unadjusted rates of neonatal mortality and birth asphyxia were calculated for each category, overall and among term deliveries with birthweight >2500g. Multivariable logistic regression was used to control for confounders. Deliveries in rural hospitals were analyzed separately using different volume categories. Results Prevalence of asphyxia increased with decreasing hospital volume overall and among term, non-low-birthweight infants, from 9 per 10,000 live births at highest-volume hospitals to 18/10,000 live births at the lowest-volume hospitals (p<0.001). Similar trends were observed in rural hospitals, with rates increasing from 7 to 34 per 10,000 live births in low-volume rural hospitals (p<0.001). Conclusion These findings provide evidence for an inverse association between hospital obstetric volume and birth asphyxia.

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Section: Methodsmentioning

confidence: 99%

Section: Commentmentioning

confidence: 99%

The association between hospital obstetric volume and perinatal outcomes in California

Snowden

Cheng

Kontgis

et al. 2012

American Journal of Obstetrics and Gynecology

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“…29–32 Prior research indicates that 23-60% of rural women give birth in non-local hospitals; however, most of these studies were limited to a single state or metropolitan area. 29,31,32 Our 25.4% non-local delivery rate for rural women in the nine study states was consistent with a 2003 study using data from seven states, 30 but updates prior estimates and improves upon the accuracy of measurement of non-local childbirth by allowing for more than one local hospital and using driving distances rather than straight-line distances.…”

Section: Commentmentioning

confidence: 99%

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

Kozhimannil

Casey

Hung

et al. 2016

American Journal of Obstetrics and Gynecology

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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.

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confidence: 99%

“…5,6 A study of over 2.6 million births in California found that rural women who were able to deliver in a rural hospital had decreased rates of morbidity and mortality. 7 However, rural hospitals continue to close labor and delivery units.8 If a local family physician provided obstetric care at a local hospital, women would not have to travel such distances and may see improvement in outcomes.We agree that all patients deserve nothing less than highly qualified, competent physicians. Our concern is not simply that the numbers of family physicians delivering babies is decreasing.…”

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confidence: 99%

Re: The Numbers Quandary in Family Medicine Obstetrics

et al. 2018

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1 brings up some important points including outcomes and training. As described, there are several studies that demonstrate equivalent outcomes between family physicians and obstetricians. Worth voices concern about the paucity in outcomes literature based on various limitations. Of the 3 recent studies cited, 1 is in Canada, which, while there are clear health care differences, presumably the patients and procedures are not so different that we must exclude it.2 The other 2 articles cited had over 14,000 patients and found a significantly lower cesarean-section rate among patients delivered by family physicians with all other outcomes equivalent whether delivery was attended by a family physician or obstetrician.3,4 These studies support previous research documenting equivalent outcomes, and leave us wondering how many times does equivalency in outcomes need to be demonstrated. However, with recent changes in family medicine training requirements, we do agree that there is a need for new studies to assess how these changes may affect outcomes in obstetric care.Regarding training standards, family medicine is a broad field with many competing interests. Decades of work conducted by the family medicine community, Accreditation Council for Graduate Medical Education (ACGME), and Family Medicine Residency Review Committee (RRC) has been done to ensure competency is achieved in each of the Family Medicine domains of practice, including obstetrics. Despite the lowered ACGME obstetric requirements, more intensive training in obstetrics via electives, mentoring, or fellowship is available for physicians interested in increasing their obstetric experience.Our finding that 23% of recent graduates want to include obstetric deliveries is encouraging both for believers in the full spectrum of family medicine and for patients who are facing higher maternal and infant morbidity. 5,6 A study of over 2.6 million births in California found that rural women who were able to deliver in a rural hospital had decreased rates of morbidity and mortality. 7 However, rural hospitals continue to close labor and delivery units.8 If a local family physician provided obstetric care at a local hospital, women would not have to travel such distances and may see improvement in outcomes.We agree that all patients deserve nothing less than highly qualified, competent physicians. Our concern is not simply that the numbers of family physicians delivering babies is decreasing. Our concern is that at a time of national shortage of obstetric care, there are 2000 family physicians who intended to provide obstetric care after graduating and are being prevented by barriers that have nothing to do with their training or competence. We might improve maternal and infant morbidity if the family physicians who are interested and competent in obstetric care are able to provide that care.

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Trends in Rural and Urban Deliveries and Vaginal Births: California 1998‐2002

Cited by 10 publications

References 14 publications

The association between hospital obstetric volume and perinatal outcomes in California

The association between hospital obstetric volume and perinatal outcomes in California

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

Re: The Numbers Quandary in Family Medicine Obstetrics

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