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Objective: The goal of this study was to characterize racial-ethnic differences in mental health care utilization associated with postpartum depression in a multiethnic cohort of Medicaid recipients.Methods: In a retrospective cohort study, administrative claims data from New Jersey's Medicaid program were obtained for 29,601 women (13,001 whites, 13,416 blacks, and 3,184 Latinas) who delivered babies between July 2004 and October 2007. Racial-ethnic differences were estimated with logistic regression for initiation of antidepressant medication or outpatient mental health visits within six months of delivery, follow-up (a prescription refill or second visit), and continued mental health care (at least three visits or three filled antidepressant prescriptions within 120 days).Results: Nine percent (N=1,120) of white women initiated postpartum mental health care, compared with 4% (N=568) of black women and 5% (N=162) of Latinas. With analyses controlling for clinical factors, the odds of initiating treatment after delivery were significantly (p<.001) lower for blacks (adjusted odds ratio [AOR]=.43) and Latinas (AOR=.59) compared with whites. Among those who initiated treatment, blacks and Latinas were less likely than whites to receive follow-up treatment (blacks, AOR=.66, p<.001; Latinas, AOR=.67, p<.05) or continued care (blacks, AOR=.81, p=.069; Latinas, AOR=.67, p<.05). Among those who initiated antidepressant treatment, black women and Latinas were less likely than whites to refill a prescription.Conclusions: There were significant racial-ethnic differences in depression-related mental health care after delivery. Suboptimal treatment was prevalent among all low-income women in the study. However, racial and ethnic disparities in the initiation and continuation of postpartum depression care were particularly troubling and warrant clinical and policy attention. [ABSTRACT FROM AUTHOR]

In the United States, the field of women's health faces critical challenges. This article, part of the National Academy of Medicine's Vital Directions for Health and Health Care: Priorities for 2025 initiative, emphasizes the need for a holistic, lifespan approach to women's health that considers biological sex, gender, and intersecting social factors. We identify three key challenges: broadening the understanding of women's health beyond reproductive issues, improving the research ecosystem, and addressing workforce limitations. With innovative policies and investments across all areas of health, attention to structural determinants, and emphasis on the upstream factors affecting women's lives, significant improvements in women's health outcomes and substantial societal benefits can be achieved in 2025 and beyond.

Purpose of Review: Improving maternal health is a clinical and policy priority in the United States. We reviewed recent literature on access to maternity care and impacts on racial and geographic equity., Recent Findings: New research indicates a wide range of consequences of obstetric unit closures, as well as health challenges for lower-volume obstetric units and those who travel long distances to care., Summary: As maternal mortality rates rise, maternity care access is declining in the US, especially in rural areas and communities with a higher proportion of Black, Latinx, or Indigenous residents. Lack of resources and financial strain are challenges for low-volume and Black-serving obstetric units, and targeted investments may help improve safety and access., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: American Indian and Alaska Native (AI/AN) people in the United States face elevated childbirth-related risks when compared with non-Hispanic white people. Access to health care is a treaty right of many AI/AN people, often facilitated through the Indian Health Service (IHS), but many AI/AN people do not qualify for or cannot access IHS care and rely on health insurance coverage to access care in other facilities. Our goal was to describe health insurance coverage and access to IHS care before, during, and after childbirth for AI/AN birthing people in the United States., Methods: We analyzed 2016 to 2020 Pregnancy Risk Assessment Monitoring System data (44 states and two other jurisdictions) for 102,860 postpartum individuals (12,920 AI/AN and 89,940 non-Hispanic white). We calculated weighted percentages, adjusted predicted probabilities, and percentage point differences for health care coverage (insurance type and IHS care) before, during, and after childbirth., Results: Approximately 75% of AI/AN birthing people did not have IHS care around the time of childbirth. AI/AN people had greater variability in insurance coverage and more insurance churn (changes in type of insurance, including between coverage and no coverage) during the perinatal period, compared with non-Hispanic white people. Health care coverage differed for rural and urban AI/AN people, with rural AI/AN residents having the lowest prevalence of continuous insurance (60%)., Conclusion: AI/AN birthing people experience insurance churning and limited access to IHS care during the perinatal period. Efforts to improve care for AI/AN birthing people should engage federal, state, and tribal entities to ensure fulfillment of the trust responsibility of the United States and to address health inequities., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Access to pregnancy-related and childbirth-related health care for rural residents is limited by health workforce shortages in the United States. Although midwives are key pregnancy and childbirth care providers, the current landscape of the rural midwifery workforce is not well understood. The goal of this analysis was to describe the availability of local midwifery care in rural US communities., Methods: We developed and conducted a national survey of rural US hospitals with current or recently closed childbirth services. Maternity unit managers or administrators at 292 rural hospitals were surveyed from March to August 2021, with 133 hospitals responding (response rate 46%; 93 currently offering childbirth services, 40 recently closed childbirth services). This cross-sectional analysis describes whether rural hospitals with current or prior childbirth services had midwifery care with certified nurse-midwives available locally and whether rural communities with and without midwifery care differed by hospital-level and county-level characteristics., Results: Among hospitals surveyed, 55% of those with current and 75% of those with prior childbirth services reported no locally available midwifery care. Of the 93 rural communities with current hospital-based childbirth services, those without midwifery care were more likely to have lower populations (37% vs 33%); majority populations that were Black, Indigenous, and people of color (24% vs 10%); and hospitals where at least 50% of births were Medicaid funded (77% vs 64%), compared with communities with midwifery care. Conversely, communities with midwifery care more often had greater than 30% of patients traveling more than 30 miles for hospital-based childbirth services (38% vs 28%)., Discussion: More than half of rural hospitals surveyed reported no locally available midwifery care, and availability differed by hospital-level and county-level characteristics. Efforts to ensure pregnancy and childbirth care access for rural birthing people should include attention to the availability of local midwifery care., (© 2024 The Author(s). Journal of Midwifery & Women's Health published by Wiley Periodicals LLC on behalf of American College of Nurse Midwives (ACNM).)

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., (© 2024 The Author(s). Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Objective: To examine racial inequities in low-risk and high-risk (or "medically appropriate") cesarean delivery rates in New Jersey during the era surrounding the United States cesarean surge and peak., Study Setting and Design: This retrospective repeated cross-sectional study examined the universe of childbirth hospitalizations in New Jersey from January 1, 2000 through September 30, 2015. We estimate the likelihood of cesarean delivery by maternal race and ethnicity, with mixed-level logistic regression models, stratified by cesarean risk level designated by the Society of Maternal Fetal Medicine (SMFM)., Data Sources and Analytic Sample: We used all-payer hospital discharge data from the Healthcare Cost and Utilization Project's State Inpatient Discharge Database and linked this data to the American Hospital Association Annual Survey. ZIP-code Tabulation Area (ZCTA)-level racialized economic segregation index data were from the 2007-2011 American Community Survey. We identified 1,604,976 statewide childbirth hospitalizations using International Classification of Diseases-9-CM (ICD-9) diagnosis and procedure codes and Diagnosis-Related Group codes, and created an indicator of cesarean delivery using ICD-9 codes., Principal Findings: Among low-risk deliveries, Black patients, particularly those in the age group of 35-39 years, had higher predicted probabilities of giving birth via cesarean than White people in the same age categories (Black-adjusted predicted probability = 24.0%; vs. White-adjusted predicted probability = 17.3%). Among high-risk deliveries, Black patients aged 35 to 39 years had a lower predicted probability (by 2.7 percentage points) of giving birth via cesarean compared with their White counterparts., Conclusions: This study uncovered a lack of medically appropriate cesarean delivery for Black patients, with low-risk Black patients at higher odds of cesarean delivery and high-risk Black patients at lower odds of cesarean than their White counterparts. The significant Black-White inequities highlight the need to address misalignment of evidence-based cesarean delivery practice in the efforts to improve maternal health equity. Quality metrics that track whether cesareans are provided when medically needed may contribute to clinical and policy efforts to prevent disproportionate maternal morbidity and mortality among Black patients., (© 2024 Health Research and Educational Trust.)

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., (© 2024 The Authors. The Journal of Rural Health published by Wiley Periodicals LLC on behalf of National Rural Health Association.)

Objective: To implement use of obstetric (OB) hospitalist telemedicine services (TeleOB) to support clinicians facing OB emergencies in low-resource hospital settings. Methods: TeleOB was staffed by OB hospitalists working at a tertiary maternity center. The service was available via real-time high-definition audio/video technology for providers at 17 outlying hospitals across a health system spanning two states. The initial 25 service activations are described. Results: TeleOB supported 17 deliveries, two postpartum emergency department (ED) consultations, and four antenatal ED consultations. In 10 of 17 (59%) deliveries, teleneonatology was jointly activated to support neonatal resuscitation. Sixteen (94%) deliveries occurred in multiparas, and five (29%) resulted from spontaneous preterm labor. Eighty percent (20/25) of activations occurred in facilities without maternity services. Conclusions: A TeleOB service staffed by OB hospitalists successfully supports hospitals in an integrated health care system. TeleOB is feasible for support of hospitals with no delivery facilities or with limited maternity care resources.

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., (Copyright © 2023 Jacobs Institute of Women's Health, George Washington University. Published by Elsevier Inc. All rights reserved.)

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., (© 2023 The Authors. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Importance: Pursuant to the Families First Coronavirus Response Act (FFCRA), continuous Medicaid eligibility during the COVID-19 public health emergency (PHE) created a de facto national extension of pregnancy Medicaid eligibility beyond 60 days postpartum., Objective: To evaluate the association of continuous Medicaid eligibility with postpartum health insurance, health care use, breastfeeding, and depressive symptoms., Design, Setting, and Participants: This cohort study using a generalized difference-in-differences design included 21 states with continuous prepolicy (2017-2019) and postpolicy (2020-2021) participation in the Pregnancy Risk Assessment Monitoring System (PRAMS)., Exposures: State-level change in Medicaid income eligibility after 60 days postpartum associated with the FFCRA measured as a percent of the federal poverty level (FPL; ie, the difference in 2020 income eligibility thresholds for pregnant people and low-income adults/parents)., Main Outcomes and Measures: Health insurance, postpartum visit attendance, contraceptive use (any effective method; long-acting reversible contraceptives), any breastfeeding and depressive symptoms at the time of the PRAMS survey (mean [SD], 4 [1.3] months postpartum)., Results: The sample included 47 716 PRAMS respondents (64.4% aged <30 years; 18.9% Hispanic, 26.2% non-Hispanic Black, 36.3% non-Hispanic White, and 18.6% other race or ethnicity) with a Medicaid-paid birth. Based on adjusted estimates, a 100% FPL increase in postpartum Medicaid eligibility was associated with a 5.1 percentage point (pp) increase in reported postpartum Medicaid enrollment, no change in commercial coverage, and a 6.6 pp decline in uninsurance. This represents a 40% reduction in postpartum uninsurance after a Medicaid-paid birth compared with the prepolicy baseline of 16.7%. In subgroup analyses by race and ethnicity, uninsurance reductions were observed only among White and Black non-Hispanic individuals; Hispanic individuals had no change. No policy-associated changes were observed in other outcomes., Conclusions and Relevance: In this cohort study, continuous Medicaid eligibility during the COVID-19 PHE was associated with significantly reduced postpartum uninsurance for people with Medicaid-paid births, but was not associated with postpartum visit attendance, contraception use, breastfeeding, or depressive symptoms at approximately 4 months postpartum. These findings, though limited to the context of the COVID-19 PHE, may offer preliminary insight regarding the potential impact of post-pandemic postpartum Medicaid eligibility extensions. Collection of longer-term and more comprehensive follow-up data on postpartum health care and health will be critical to evaluating the effect of ongoing postpartum policy interventions.

A growing number of studies are using birth certificate data, despite data-quality concerns, to study maternal morbidity and associated disparities. We examined whether conclusions about the incidence of maternal morbidity, including Black-White disparities, differ between birth certificate data and hospitalization data. Using linked birth certificate and hospitalization data from California and Michigan for 2018 (N=543,469), we found that maternal morbidity measures using birth certificate data alone are substantially underreported and have poor validity. Furthermore, the degree of underreporting in birth certificate data differs between Black and White individuals and results in erroneous inferences about disparities. Overall, Black-White disparities were more modest in the birth certificate data compared with the hospitalization data. Birth certificate data alone are inadequate for studies of maternal morbidity and associated racial disparities., Competing Interests: Financial Disclosure The authors did not report any potential conflicts of interest., (Copyright © 2024 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Societal systems act individually and in combination to create and perpetuate structural racism through both policies and practices at the local, state, and federal levels, which, in turn, generate racial and ethnic health disparities. Both current and historical policy approaches across multiple sectors-including housing, employment, health insurance, immigration, and criminal legal-have the potential to affect child health equity. Such policies must be considered with a focus on structural racism to understand which have the potential to eliminate or at least attenuate disparities. Policy efforts that do not directly address structural racism will not achieve equity and instead worsen gaps and existing disparities in access and quality-thereby continuing to perpetuate a two-tier system dictated by racism. In Paper 2 of this Series, we build on Paper 1's summary of existing disparities in health-care delivery and highlight policies within multiple sectors that can be modified and supported to improve health equity, and, in so doing, improve the health of racially and ethnically minoritised children., Competing Interests: Declaration of interests AC has a contract with Organon & Co (previously part of Merck) as a clinical trainer for the Nexplanon contraceptive device. In this role, she provides training and education to resident physicians at her institution in the use of the subdermal implant device. She does not receive payment or any other form of incentive from Organon & Co in this role NH-G is the co-owner of XNY Genes. All other authors declare no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Competing Interests: Financial Disclosure The authors did not report any potential conflicts of interest.

Objective: To evaluate whether there are individual- and population-level associations between chronic hypertension and pregnancy complications, and to assess differences across seven racial-ethnic groups., Methods: This population-based study used linked vital statistics and hospitalization discharge data from all live and stillbirths in California (2008-2018), Michigan (2008-2020), Oregon (2008-2020), Pennsylvania (2008-2014), and South Carolina (2008-2020). We used multivariable log-binomial regression models to estimate risk ratios (RRs) and population attributable risk (PAR) percentages with 95% CIs for associations between chronic hypertension and several obstetric and neonatal outcomes, selected based on prior evidence and pathologic pathways. We adjusted models for demographic factors (race and ethnicity, payment method, educational attainment), age, body mass index, obstetric history, delivery year, and state, and conducted analyses stratified across seven racial-ethnic groups., Results: The study included 7,955,713 pregnancies, of which 168,972 (2.1%) were complicated by chronic hypertension. Chronic hypertension was associated with several adverse obstetric and neonatal outcomes, with the largest adjusted PAR percentages observed for preeclampsia with severe features or eclampsia (22.4; 95% CI 22.2-22.6), acute renal failure (13.6; 95% CI 12.6-14.6), and pulmonary edema (10.7; 95% CI 8.9-12.6). Estimated RRs overall were similar across racial-ethnic groups, but PAR percentages varied. The adjusted PAR percentages (95% CI) for severe maternal morbidity-a widely used composite of acute severe events-for people who were American Indian or Alaska Native, Asian, Black, Latino, Native Hawaiian or Other Pacific Islander, White, and Multiracial or Other were 5.0 (1.1-8.8), 3.7 (3.0-4.3), 9.0 (8.2-9.8), 3.9 (3.6-4.3), 11.6 (6.4-16.5), 3.2 (2.9-3.5), and 5.5 (4.2-6.9), respectively., Conclusion: Chronic hypertension accounts for a substantial fraction of obstetric and neonatal morbidity and contributes to higher complication rates, particularly for people who are Black or Native Hawaiian or Other Pacific Islander., Competing Interests: Financial Disclosure Ciaran S. Phibbs received payment from Nelson Mullins Riley & Scarborough as expert witness, which is not related to this article. The other authors did not report any potential conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Despite efforts to improve postpartum health care in the United States, little is known about patterns of postpartum care beyond routine postpartum visit attendance. This study aimed to describe variation in outpatient postpartum care patterns., Methods: In this longitudinal cohort study of national commercial claims data, we used latent class analysis to identify subgroups of patients (classes) with similar outpatient postpartum care patterns (defined by the number of preventive, problem, and emergency department outpatient visits in the 60 days after birth). We also compared classes in terms of maternal sociodemographics and clinical characteristics measured at childbirth, as well as total health spending and rates of adverse events (all-cause hospitalizations and severe maternal morbidity) measured from childbirth to the late postpartum period (61-365 days after birth)., Results: The study cohort included 250,048 patients hospitalized for childbirth in 2016. We identified six classes with distinct outpatient postpartum care patterns in the 60 days after birth, which we classified into three broad groups: no care (class 1 [32.4% of the total sample]); preventive care only (class 2 [18.3%]); and problem care (classes 3-6 [49.3%]). The prevalence of clinical risk factors at childbirth increased progressively from class 1 to class 6; for example, 6.7% of class 1 patients had any chronic disease compared with 15.5% of class 5 patients. Severe maternal morbidity was highest among the high problem care classes (classes 5 and 6): 1.5% of class 6 patients experienced severe maternal morbidity in the postpartum period and 0.5% in the late postpartum period, compared with less than 0.1% of patients in classes 1 and 2., Conclusions: Efforts to redesign and measure postpartum care should reflect the current heterogeneity in care patterns and clinical risks in the postpartum population., (Copyright © 2023 Jacobs Institute of Women's Health, George Washington University. Published by Elsevier Inc. All rights reserved.)

Measures of perinatal care quality and outcomes often focus on either the birth parent or the infant. We used linked vital statistics and hospital discharge data to describe a dyadic measure (including both the birth parent and the infant) for perinatal care during the birth hospitalization. In this five-state cohort of 2010-18 births, 21.6 percent of birth parent-infant dyads experienced at least one complication, and 9.6 percent experienced a severe complication. Severe infant complications were eight times more prevalent than severe birth parent complications. Among birth parents with a severe complication, the co-occurrence of a severe infant complication ranged from 2 percent to 51 percent, whereas among infants with a severe complication, the co-occurrence of a severe birth parent complication was rare, ranging from 0.04 percent to 5 percent. These data suggest that measures, clinical interventions, public reporting, and policies focused on either the birth parent or the infant are incomplete in their assessment of a healthy dyad. Thus, clinicians, administrators, and policy makers should evaluate dyadic measures, incentivize positive outcomes for both patients (parent and infant), and create policies that support the health of the dyad.

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., Competing Interests: Please see ICMJE form(s) for author conflicts of interest. These have been provided as supplementary materials., (© The Author(s) 2023. Published by Oxford University Press on behalf of Project HOPE - The People-To-People Health Foundation, Inc.)

Importance: Identifying hospital factors associated with severe maternal morbidity (SMM) is essential to clinical and policy efforts., Objective: To assess associations between obstetric volume and SMM in rural and urban hospitals and examine whether these associations differ for low-risk and higher-risk patients., Design, Setting, and Participants: This retrospective cross-sectional study of linked vital statistics and patient discharge data was conducted from 2022 to 2023. Live births and stillbirths (≥20 weeks' gestation) at hospitals in California (2004-2018), Michigan (2004-2020), Pennsylvania (2004-2014), and South Carolina (2004-2020) were included. Data were analyzed from December 2022 to May 2023., Exposures: Annual birth volume categories (low, medium, medium-high, and high) for hospitals in urban (10-500, 501-1000, 1001-2000, and >2000) and rural (10-110, 111-240, 241-460, and >460) counties., Main Outcome and Measures: The main outcome was SMM (excluding blood transfusion); covariates included age, payer status, educational attainment, race and ethnicity, and obstetric comorbidities. Analyses were stratified for low-risk and higher-risk obstetric patients based on presence of at least 1 clinical comorbidity., Results: Among more than 11 million urban births and 519 953 rural births, rates of SMM ranged from 0.73% to 0.50% across urban hospital volume categories (high to low) and from 0.47% to 0.70% across rural hospital volume categories (high to low). Risk of SMM was elevated for patients who gave birth at rural hospitals with annual birth volume of 10 to 110 (adjusted risk ratio [ARR], 1.65; 95% CI, 1.14-2.39), 111 to 240 (ARR, 1.37; 95% CI, 1.10-1.70), and 241 to 460 (ARR, 1.26; 95% CI, 1.05-1.51), compared with rural hospitals with greater than 460 births. Increased risk of SMM occurred for low-risk and higher-risk obstetric patients who delivered at rural hospitals with lower birth volumes, with low-risk rural patients having notable discrepancies in SMM risk between low (ARR, 2.32; 95% CI, 1.32-4.07), medium (ARR, 1.66; 95% CI, 1.20-2.28), and medium-high (ARR, 1.68; 95% CI, 1.29-2.18) volume hospitals compared with high volume (>460 births) rural hospitals. Among hospitals in urban counties, there was no significant association between birth volume and SMM for low-risk or higher-risk obstetric patients., Conclusions and Relevance: In this cross-sectional study of births in US rural and urban counties, risk of SMM was elevated for low-risk and higher-risk obstetric patients who gave birth in lower-volume hospitals in rural counties, compared with similar patients who gave birth at rural hospitals with greater than 460 annual births. These findings imply a need for tailored quality improvement strategies for lower volume hospitals in rural communities.

Background: In contrast to other high-resource countries, the United States has experienced increases in the rates of severe maternal morbidity. In addition, the United States has pronounced racial and ethnic disparities in severe maternal morbidity, especially for non-Hispanic Black people, who have twice the rate as non-Hispanic White people., Objective: This study aimed to examine whether the racial and ethnic disparities in severe maternal morbidity extended beyond the rates of these complications to include disparities in maternal costs and lengths of stay, which could indicate differences in the case severity., Study Design: This study used California's linkage of birth certificates to inpatient maternal and infant discharge data for 2009 to 2011. Of the 1.5 million linked records, 250,000 were excluded because of incomplete data, for a final sample of 1,262,862. Cost-to-charge ratios were used to estimate costs from charges (including readmissions) after adjusting for inflation to December 2017. Mean diagnosis-related group-specific reimbursement was used to estimate physician payments. We used the Centers for Disease Control and Prevention definition of severe maternal morbidity, including readmissions up to 42 days after delivery. Adjusted Poisson regression models estimated the differential risk of severe maternal morbidity for each racial or ethnic group, compared with the non-Hispanic White group. Generalized linear models estimated the associations of race and ethnicity with costs and length of stay., Results: Asian or Pacific Islander, Non-Hispanic Black, Hispanic, and other race or ethnicity patients all had higher rates of severe maternal morbidity than non-Hispanic White patients. The largest disparity was between non-Hispanic White and non-Hispanic Black patients, with unadjusted overall rates of severe maternal morbidity of 1.34% and 2.62%, respectively (adjusted risk ratio, 1.61; P<.001). Among patients with severe maternal morbidity, the adjusted regression estimates showed that non-Hispanic Black patients had 23% (P<.001) higher costs (marginal effect of $5023) and 24% (P<.001) longer hospital stays (marginal effect of 1.4 days) than non-Hispanic White patients. These effects changed when cases, such as cases where a blood transfusion was the only indication of severe maternal morbidity, were excluded, with 29% higher costs (P<.001) and 15% longer length of stay (P<.001). For other racial and ethnic groups, the increases in costs and length of stay were smaller than those observed for non-Hispanic Black patients, and many were not significantly different from non-Hispanic White patients. Hispanic patients had higher rates of severe maternal morbidity than non-Hispanic White patients; however, Hispanic patients had significantly lower costs and length of stay than non-Hispanic White patients., Conclusion: There were racial and ethnic differences in the costs and length of stay among patients with severe maternal morbidity across the groupings that we examined. The differences were especially large for non-Hispanic Black patients compared with non-Hispanic White patients. Non-Hispanic Black patients experienced twice the rate of severe maternal morbidity; in addition, the higher relative costs and longer lengths of stay for non-Hispanic Black patients with severe maternal morbidity support greater case severity in that population. These findings suggest that efforts to address racial and ethnic inequities in maternal health need to consider differences in case severity in addition to the differences in the rates of severe maternal morbidity and that these differences in case severity merit additional investigation., (Published by Elsevier Inc.)

Objective: To measure variation in delivery-related severe maternal morbidity (SMM) among individuals with Medicaid insurance by state and by race and ethnicity across and within states., Methods: We conducted a pooled, cross-sectional analysis of the 2016-2018 TAF (Transformed Medicaid Statistical Information System Analytic Files). We measured overall and state-level rates of SMM without blood transfusion for all individuals with Medicaid insurance with live births in 49 states and Washington, DC. We also examined SMM rates among non-Hispanic Black and non-Hispanic White individuals with Medicaid insurance in a subgroup of 27 states (and Washington, DC). We generated unadjusted rates of composite SMM and the individual indicators of SMM that comprised the composite. Rate differences and rate ratios were calculated to compare SMM rates for non-Hispanic Black and non-Hispanic White individuals with Medicaid insurance., Results: The overall rate of SMM without blood transfusion was 146.2 (95% CI 145.1-147.3) per 10,000 deliveries (N=4,807,143). Rates of SMM ranged nearly threefold, from 80.3 (95% CI 71.4-89.2) per 10,000 deliveries in Utah to 210.4 (95% CI 184.6-236.1) per 10,000 deliveries in Washington, DC. Non-Hispanic Black individuals with Medicaid insurance (n=629,774) experienced a higher overall rate of SMM (212.3, 95% CI 208.7-215.9) compared with non-Hispanic White individuals with Medicaid insurance (n=1,051,459); (125.3, 95% CI 123.2-127.4) per 10,000 deliveries (rate difference 87.0 [95% CI 82.8-91.2]/10,000 deliveries; rate ratio 1.7 [95% CI 1.7-1.7]). The leading individual indicator of SMM among all individuals with Medicaid insurance was eclampsia, although the leading indicators varied across states and by race and ethnicity. Many states were concordant in leading indicators among the overall, non-Hispanic Black, and non-Hispanic White populations (ie, in Oklahoma sepsis was the leading indicator for all three). Most states, however, were discordant in leading indicators across the three groups (ie, in Texas eclampsia was the leading indicator overall, pulmonary edema or acute heart failure was the leading indicator among the non-Hispanic Black population, and sepsis was the leading indicator among the non-Hispanic White population)., Conclusion: Interventions aimed at reducing SMM and, ultimately, mortality among individuals with Medicaid insurance may benefit from the data generated from this study, which highlights states that have the greatest burden of SMM, the differences in rates among non-Hispanic Black populations compared with non-Hispanic White populations, and the leading indicators of SMM overall, by state, and by race and ethnicity., Competing Interests: Financial Disclosure Lindsay K. Admon reports receiving payment as a consultant for NIH, HRSA, the Commonwealth Fund, MACPAC, ACOG, and the CDC. Sarah Gordon is a senior advisor on health policy in the Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services. However, this article was conceived and drafted while Dr. Gordon was employed at Boston University, and findings and views in this article do not reflect the official views or policy of the Department of Health and Human Services. The other authors did not report any potential conflicts of interest., (Copyright © 2023 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

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., Competing Interests: Financial Disclosure Lindsay K. Admon reports receiving consulting fees from the NIMHD, grant UG3HD1080053 (PI Bauer) and grant R01MD016892 (PI Peet); HRSA, grant No. U1CRH03717 (PI Kozhimannil); the Commonwealth Fund, grant 20224055 (PI Gordon); and Medicaid and CHIP Payment and Access Commission (MACPAC) Consulting. The following entities paid consulting fees to her institution's department: Division of Reproductive Health, Centers for Disease Control and Prevention, the ACOG Health Policy Division, and the Commonwealth Fund. The other authors did not report any potential conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

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).

Objective: The aim of the study is to determine the relationship between a hospital's provision of subspecialty neonatal and maternal care. Specifically, we sought to understand where women with high-risk maternal conditions received intrapartum care and estimate the potential transfer burden for those with maternal high-risk conditions delivering at hospitals without subspecialty maternal care., Study Design: This is a descriptive study using data from 2015 State Inpatient Databases and the American Hospital Association Annual Survey. Characteristics were compared between hospitals based on the concordance of their maternal and neonatal care. The incidences of high-risk maternal conditions (pre-eclampsia with severe features, placenta previa with prior cesarean delivery, cardiac disease, pulmonary edema, and acute liver failure) were compared. To determine the potential referral burden, the percent of women with high-risk conditions delivering at a hospital without subspecialty maternal care but delivering in a county with a hospital with subspecialty maternal care was calculated., Results: The analysis included 486,398 women who delivered at 544 hospitals, of which 104 (19%) and 182 (33%) had subspecialty maternal and neonatal care, respectively. Ninety-eight hospitals provided both subspecialty maternal and neonatal care; however, 84 hospitals provided only subspecialty neonatal care but no subspecialty maternal care. Among high-risk maternal conditions examined, approximately 65% of women delivered at a hospital with subspecialty maternal care. Of the remainder who delivered at a hospital without subspecialty maternal care, one-third were in a county where subspecialty care was present. For women with high-risk conditions who delivered in a county without subspecialty maternal care, the median distance to the closest county with subspecialty care was 52.8 miles (IQR: 34.3-87.7 miles)., Conclusion: Approximately 50% of hospitals with subspecialty neonatal care do not provide subspecialty maternal care. This discordance may present a challenge when both high-risk maternal and neonatal conditions are present., Key Points: · High-risk women who deliver at hospitals without subspecialty care are in more rural areas.. · Approximately 50% of hospitals with subspecialty neonatal care do not provide subspecialty maternal care.. · This discordance may present a challenge when both high-risk maternal and neonatal conditions are present.., Competing Interests: M.A.C. reports grants from American College of Obstetricians and Gynecologists, during the conduct of the study. The other authors report no conflict of interest., (Thieme. All rights reserved.)

Objective: To describe the experiences of pregnancy and birth after cesarean of women who live in rural areas of the United States, including access to vaginal birth after cesarean (VBAC), type of maternity care provider, travel times, autonomy in decision making, and respectful maternity care., Design: Retrospective observational study., Setting: Online questionnaire of women who gave birth in the United States., Participants: Women (N = 1,711) with histories of cesarean and subsequent births within 5 years of participating., Methods: We calculated descriptive and bivariate statistics by identified areas of residence and stratified measures of autonomy and respectful maternity care by self-identification as a member of a racialized group. We applied qualitative descriptive analysis to responses to an open-ended survey question., Results: A total of 299 (17.5%) participants identified their areas of residence as rural. Similar percentages of rural and metropolitan participants were able to plan VBAC (p = .88). More rural participants than metropolitan participants reported travel times of more than 60 minutes to give birth (p < .001), and fewer had obstetricians (p = .002) or doulas (p = .03). Rural participants from racialized groups experienced significantly less respectful maternity care than White, non-Hispanic rural participants and all metropolitan participants (p = .04). Qualitative data illustrating the main findings are included., Conclusions: Our findings highlight challenges faced by rural residents accessing VBAC and help explain why rates of VBAC in rural areas remain low. We suggest a range of clinical and policy strategies to improve access to VBAC in rural areas and to improve the quality of maternity care for racialized women who live in rural areas., Competing Interests: Conflict of Interest The authors report no conflicts of interest or relevant financial relationships., (Copyright © 2022 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

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., (© 2022. The Author(s), under exclusive licence to Springer Nature America, Inc.)

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., (Copyright © 2022 Jacobs Institute of Women's Health, George Washington University. Published by Elsevier Inc. All rights reserved.)

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.

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.

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 ( a OR 0.36, 95% CI 0.13-0.97), midwifery care ( a OR 0.35, 95% CI 0.12-0.99), doula support ( a OR 0.30, 95% CI 0.11-0.84), postpartum support groups ( a OR 0.25, 95% CI 0.09-0.68), and childbirth education classes ( a OR 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.

Introduction: The objectives of this study were to include readmissions and physician costs in the estimates of total costs of severe maternal morbidity (SMM), to consider the effect of SMM on maternal length of stay (LOS), and to examine these for the more restricted definition of SMM that excludes transfusion-only cases., Methods: California linked birth certificate-patient discharge data for 2009 through 2011 (n = 1,262,862) with complete costs and LOS were used in a secondary data analysis. Cost-to-charge ratios were used to estimate costs from charges, adjusting for inflation. Physician payments were estimated from the mean payments for specific diagnosis-related groups. Generalized linear models estimated the association between SMM and costs and LOS., Results: Excluding readmissions and physician costs, SMM was associated with a 60% increase in hospital costs (marginal effect [ME] $3,550) and a 33% increase in LOS (ME 0.9 days). These increased to 70% (ME $5,806) and 46% (ME 1.3 days) when physician costs and readmissions were included. The effects of SMM were roughly one-half as large for patients who only required a blood transfusion (49% [ME $4,056] and 31% [ME 0.9 days]) as for patients who had another indicator for SMM (93% [ME $7,664] and 62% [ME 1.7 days])., Conclusions: Postpartum hospital readmissions and physician costs are important and previously unreported contributors to the costs of SMM. Excess costs and LOS associated with SMM vary considerably by indication. Cost effects were larger than the LOS effects, indicating that SMM increases treatment intensity beyond increasing LOS, and decreasing SMM may have broader health and cost benefits than previously understood., (Published by Elsevier Inc.)

Introduction: Racial and ethnic disparities in perinatal health outcomes are among the greatest threats to population health in the United States. Black birthing communities are most impacted by these inequities due to structural racism throughout society and within health care settings. Although multiple studies have shown that structural racism and the disrespect associated with this system of inequity are the root causes of observed perinatal inequities, little scholarship has centered the needs of Black birthing communities to create alternative care models. Leaning on reproductive justice and critical race theoretical frameworks, this study explores good birth experiences as described by Black birthing people., Methods: Thematic analysis of two focus groups and three one-on-one interviews conducted with clients at a Black-owned free-standing culturally-centered birth center (n=10)., Results: We found that Black birthing persons' concerns centered on three main themes: agency, historically- and culturally-safe birthing experiences, and relationship-centered care. Many participants pointed directly to past experiences of medical mistreatment and obstetric racism when defining their ideal birth experience., Conclusion: Black birthing people seeking care from culturally-informed providers often do so because they have been mistreated, disregarded, and neglected within traditional care settings. The needs articulated by our study participants provide a powerful framework for understanding alternative patient-centered models of care that can be developed to improve the care experiences of Black birthing people in the pursuit of birth equity.

Objective: To examine the association between severe maternal morbidity (SMM) and infant health using the additional infant costs and length of stay (LOS) as markers of added clinical complexity., Study Design: Secondary data analysis using California linked birth certificate-patient discharge data for 2009-2011 (N = 1,260,457). Regression models were used to estimate the association between SMM and infant costs and LOS., Results: The 16,687 SMM-exposed infants experienced a $6550 (33%) increase in costs and a 0.7 (18%) day increase in LOS. Preterm infants had ($11,258 (18%) added costs and 1.3 days (8.1%) longer LOS) than term infants ($2539 (38%) added costs and 0.5 days (22%) longer LOS)., Conclusions: SMM was associated with increased infant costs and LOS, suggesting that SMM may have adverse health effects for infants, including term infants. The relatively larger effect on costs indicates an increase in treatment intensity (clinical severity) greater than additional LOS., (© 2022. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

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.

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., Competing Interests: Conflict of Interest Disclosures: Dr Kozhimannil, Ms Interrante, and Dr Admon reported support from the Health Resources and Services Administration PHS Cooperative Agreement No. 5U1CRH03717. Dr Kozhimannil and Dr Basile Ibrahim reported support from the National Institutes of Health National Center for Advancing Translational Sciences, grant UL1TR002494. Dr Admon also reported a grant from AHRQ K08HS027640 during the conduct of the study; as well as grants from National Institutes of Health (NIH) R01MH120124, grants from NIH R01MD014958, grants from the Commonwealth Fund, personal fees from American College of Obstetricians and Gynecologists Consultant, personal fees from Centers for Disease Control and Prevention Consultant, personal fees from Medicaid and CHIP Payment and Access Commission Consultant, and personal fees from NIH., (Copyright 2022 Kozhimannil KB et al. JAMA Health Forum.)

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.

Purpose: For reproductive-age women, medications for opioid use disorder (OUD) decrease risk of overdose death and improve outcomes but are underutilized. Our objective was to provide a qualitative description of reproductive-age women's experiences of seeking an appointment for medications for OUD., Methods: Trained female callers placed telephone calls to a representative sample of publicly listed opioid treatment clinics and buprenorphine providers in Florida, Kentucky, Massachusetts, Michigan, Missouri, North Carolina, Tennessee, Virginia, Washington, and West Virginia to obtain appointments to receive medication for OUD. Callers were randomly assigned to be pregnant or non-pregnant and have private or Medicaid-based insurance to assess differences in the experiences of access by these characteristics. The callers placed 28,651 uniquely randomized calls, 10,117 to buprenorphine-waivered prescribers and 754 to opioid treatment programs. Open-ended, qualitative data were obtained from the callers about the access experiences and were analyzed using a qualitative, iterative inductive-deductive approach. From all 28,651 total calls, there were 17,970 unique free-text comments to the question "Please give an objective play-by-play of the description of what happened in this conversation.", Findings: Analysis demonstrated a common path to obtaining an appointment. Callers frequently experienced long hold times, multiple transfers, and difficult interactions. Clinic receptionists were often mentioned as facilitating or obstructing access. Pregnant callers and those with Medicaid noted more barriers. Obtaining an appointment was commonly difficult even for these persistent, trained callers., Conclusions: Interventions are needed to improve the experiences of reproductive-age women as they enter care for OUD, especially for pregnant women and those with Medicaid coverage., (Copyright © 2021 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Increases in postpartum maternal deaths, including a substantial number associated with behavioural health conditions, are a public health crisis and have contributed to overall increases in maternal mortality. A leading hypothesis to explain this pattern suggests lack of availability or continuity of resources for behavioural health treatment after delivery, often secondary to lapses in insurance coverage. Extending postpartum Medicaid coverage through the first year postpartum could mitigate excess morbidity and mortality among postpartum individuals, particularly those with behavioural health conditions.

Racial and ethnic inequities in health are a national crisis requiring engagement across a range of factors, including the health care workforce. Racial inequities in maternal and infant health are an increasing focus of attention in the wake of rising rates of maternal morbidity and mortality in the United States. Efforts to achieve racial equity in childbirth should include attention to the nurses who provide care before and during pregnancy, at childbirth, and postpartum.

Importance: To reduce postpartum uninsurance and improve postpartum health, the American Rescue Plan included an option for states to extend pregnancy-related Medicaid from 60 days to 1 year after childbirth. Recent estimates of postpartum uninsurance among Medicaid-paid births would provide information on who would benefit from state adoption of this extension., Objective: To estimate rates of postpartum uninsurance among individuals with Medicaid-paid births., Design Setting and Participants: This cross-sectional study used survey data from the 2015 to 2018 Pregnancy Risk Assessment Monitoring System (PRAMS), a representative sample of births in 43 states and New York City, New York, and included PRAMS participants for whom Medicaid was the primary payer for childbirth. The mean weighted PRAMS response rate was 60.9% for the sites and years included in this study. The data were analyzed from December 2020 to January 2021., Interventions or Exposures: Self-reported postpartum uninsurance measured at the time of the PRAMS survey (mean [interquartile range], 4.2 (3.0-5.0) months after birth)., Main Outcomes and Measures: Survey-weighted rates of postpartum uninsurance and 95% CIs overall, by state, by state Medicaid expansion status, and by maternal sociodemographic characteristics. Adjusted odds ratios of the association between maternal characteristics and postpartum uninsurance., Results: We identified 63 370 respondents with a Medicaid-paid birth. Of these, 22 016 (41.1%) were non-Hispanic White individuals, 17 442 (22.0%) non-Hispanic Black individuals, 6808 (13.3%) Spanish-speaking Hispanic individuals, 7000 (13.7%) English-speaking Hispanic individuals, 2410 (4.0%) Asian/Pacific Islander individuals, and 3894 (1.3%) Indigenous individuals. Of these, 41.7% were no longer insured by Medicaid postpartum and 22.0% were uninsured postpartum. The postpartum uninsurance rate was 3 times higher in Medicaid nonexpansion states (36.8%) compared with expansion states (12.8%). Postpartum uninsurance varied significantly across states, ranging from 1.7% in Massachusetts to 56.7% in Texas. There were substantial racial and ethnic disparities in postpartum uninsurance: 54.9% of Hispanic, Spanish-speaking individuals (adjusted odds ratio [aOR], 6.2; 95% CI, 5.5-7.0) and 42.8% of Indigenous respondents reported postpartum uninsurance (aOR, 4.3; 95% CI, 3.8-4.9) compared with 15.2% of non-Hispanic White respondents. The odds of postpartum uninsurance was higher among unmarried people (aOR, 1.3 compared with married people; 95% CI, 1.2-1.4), those 35 years and older (aOR, 1.5 compared with those younger than 20 years; 95% CI, 1.2-1.9) and those with lower levels of education (aOR, 0.8 for more than high school compared with less than high school; 95% CI, 0.7-0.9)., Conclusions and Relevance: In this cross-sectional survey study of 43 states, a high proportion of people with Medicaid-paid births were uninsured in the postpartum period, particularly those living in Medicaid nonexpansion states. The study findings suggest that state extensions of pregnancy-related Medicaid eligibility through the first year postpartum could disproportionately benefit Hispanic and Indigenous people, unmarried people, those with lower education levels, and those living in Medicaid nonexpansion states., Competing Interests: Conflict of Interest Disclosures: None reported., (Copyright 2021 Daw JR et al. JAMA Health Forum.)

Purpose: Policy and reproductive health practice changes in the past decade have affected use of different contraceptive methods, but no study has assessed contraceptive method use over this time by rural-urban residence in the United States., Methods: We used female and male respondent data (2006-2017) from the National Survey of Family Growth (n = 29,133 women and n = 24,364 men) to estimate contraceptive method use by rural-urban residence over time and contraceptive method use by age, marital status, and parity/number of children., Results: From 2006-2010 to 2013-2017, among urban women, we found increased use of two or more methods (11% to 14%); increased use of intrauterine devices (5% to 11%), implants (0 to 2%), and withdrawal (5 to 8%); and decreased use of sterilization (28% to 22%) and pills (26% to 22%). Among rural women, we found increased use of intrauterine devices (5% to 9%) and implants (1% to 5%). We found increased withdrawal use for urban men, but otherwise no differences among men across time. In data pooled across all survey periods (2006-2017), contraceptive method use varied by rural-urban residence across age, marital status, and parity/number of children., Conclusions: In a nationally representative sample of reproductive age women and men, we found rural-urban differences in contraceptive method use from 2006-2010 to 2013-2017. Describing contraceptive use differences by rural-urban residence is necessary for tailoring reproductive health services to populations appropriately., (Copyright © 2020 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)