PurposeThe Centers for Disease Control and Prevention (CDC) and the American College of Obstetrics and Gynecology have called for researchers to further elucidate medical and social determinants of pregnancy‐related death and severe maternal morbidity. This report begins to answer this call in the context of rural Appalachia.MethodsThis report identifies risk factors exposing women in rural Appalachia to pregnancy‐related death and severe maternal morbidity. We also use CDC WONDER data to illustrate rural‐urban differences in pregnancy‐related death.FindingsRural women nationally die of pregnancy‐related causes at a greater rate than urban women. It is unknown how rurality specifically influences pregnancy‐related death, but rural women more often embody multiple risk factors associated with negative maternal outcomes. Established risk factors, including high rates of chronic illness and substance abuse, place rural women at risk for severe maternal morbidity and pregnancy‐related mortality. These women may also lack the resources to mitigate these risks, including access to high‐risk obstetric care.Next stepsTo address these issues and the concerning lack of data, we propose 4 directions for future study: (1) a determination of the prevalence of pregnancy‐related death and severe maternal morbidity in this population; (2) an examination of how rural women utilize existing pre‐ and perinatal resources; (3) better validation concerning surveillance methods of pregnancy‐related death and severe maternal morbidity in rural areas; and (4) an exploratory qualitative study of rural women and health care providers.
Purpose The goal of this study was to evaluate how rural/urban status and other risk factors alter women's odds of severe maternal morbidity (SMM) at delivery. Methods This study used 48,608 Kentucky resident delivery hospitalization records from 2017. We used multiple logistic regression with interaction terms to evaluate the moderating effect of rural/urban residence with other risk factors. We reported adjusted odds ratios (aORs) and 95% confidence intervals (CIs) as measures for association with the outcome of SMM at delivery. Findings The percentage of delivery hospitalizations with SMM was higher for women with rural (2.4%) versus metro (1.1%) or metro‐adjacent (1.5%) residence (p < .001). Rural status moderated the effect of anemia on SMM. The aOR for SMM for women with anemia versus those without was 8.56 (CI: 4.89–14.97) in rural areas, two times higher than in metro areas (aOR 3.87; CI: 3.09–4.86). Kentucky Appalachian region (aOR 1.90; CI: 1.46–2.47), Black race (aOR 1.30; CI: 1.02–1.66), history of cesarean section (aOR 1.28; CI: 1.07–1.52), hypertension (aOR 10.55; CI: 5.67–19.62), and opioid use (aOR 1.72; CI: 1.19–2.47) were significantly associated with SMM. Conclusion Rural women in Kentucky are at an increased risk for SMM. Quality and safety programming should specifically address the needs of isolated subpopulations. Women living in rural areas are more likely to experience SMM given an anemia diagnosis. The underlying cause and clinical management of anemia may differ between rural and urban areas.
Background Non-suicidal self-injury and suicide attempts are increasing problems among American adolescents. This study developed a definition for identifying intentional self-harm (ISH) injuries in emergency department (ED) records coded with International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes. The definition is based on the injury-reporting framework proposed by the Centers for Disease Control and Prevention. The study sought to estimate the definition’s positive predictive value (PPV), and the proportion of ISH injuries with intent to die (i.e., suicide attempt). Methods The study definition, based on first-valid external cause-of-injury ICD-10-CM codes X71-X83, T14.91, T36-T65, or T71, captured 207 discharge records for initial encounters for ISH in one Kentucky ED. Medical records were reviewed to confirm provider-documented diagnosis for ISH, and identify intent to die or suicide ideation. The PPV of the study definition for capturing provider-documented ISH injuries was reported with its 95% confidence interval (95% CI). Results The estimated PPV for the study definition to capture ISH injuries was 88.9%, 95% CI (83.8%, 92.8%). The estimated percentage of ISH with intent to die was 45.9, 95% CI (47.1, 61.0%). The ICD-10-CM code “suicide attempt” (T14.91) captured only 7 cases, but coding guidelines restrict assignment of this code to cases in which the mechanism of the suicide attempt is unknown. Conclusions The proposed case definition supported a robust PPV for ISH injuries. Our findings add to the evidence that the current ICD-10-CM coding system and coding guidelines do not allow identification of ISH with intent to die; modifications are needed to address this issue.
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