The Rural Obstetric Workforce in US Hospitals: Challenges and Opportunities

American Journal of Obstetrics and Gynecology

Casey

Hung

et al. 2016

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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.

Section: Methodsmentioning

confidence: 99%

“…10 The challenge of ensuring that appropriate maternity services are available to meet clinical needs tops the list of concerns among rural obstetric unit managers, medical directors, and clinicians. 11 …”

Section: Introductionmentioning

confidence: 99%

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

American Journal of Obstetrics and Gynecology

Casey

Hung

et al. 2016

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“…524, 2012) but this specialized workforce supply is limited, especially in rural areas. (Kozhimannil et al, 2015; Rosenblatt et al, 2015) State and federal policy can influence clinician supply, as indicated by differential growth in physicians credentialed to provide opioid treatment based on state-level ACA implementation. (Knudsen, Lofwall, Havens, & Walsh, 2015)…”

Section: Implications For Practice and Policymentioning

confidence: 99%

Nonmedical Use of Prescription Opioids among Pregnant U.S. Women

Graves

Levy

et al. 2017

Women's Health Issues

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Objectives Nonmedical use of opioids during pregnancy is associated with adverse outcomes for women and infants, making it a prominent target for prevention and identification. Using a nationally representative sample, we determined characteristics of US pregnant women who reported prescription opioid misuse in the past year or during the past month. Methods We used data from the National Survey on Drug Use and Health (2005–2014) in a retrospective analysis. The sample included 8,721 (weighted N=23,855,041) non-institutionalized women, ages 12–44, who reported being pregnant when surveyed. Outcomes were nonmedical use of prescription opioid medications during the past 12 months and during the past 30 days. Multivariable logistic models were created to determine correlates of nonmedical opioid use after accounting for potential confounding variables. Results Among pregnant women in the US, 5.1% reported nonmedical opioid use in the past year. In adjusted models, depression or anxiety in the past year was strongly associated with past year nonmedical use (AOR=2.15 [1.52,3.04]), as were past year use of alcohol (AOR=1.56 [1.11,2.17]), tobacco (AOR 1.72 [1.17,2.53]), and marijuana (AOR 3.44 [2.47,4.81]). Additionally, 0.9% of US pregnant women reported nonmedical opioid use in the past month. Past year depression or anxiety and past month use of alcohol, tobacco, and marijuana each independently predicted past month nonmedical use. Conclusions Characteristics associated with nonmedical opioid use by pregnant women reveal populations with mental illness and co-occurring substance use. Policy and prevention efforts to improve screening and treatment could focus on the at-risk populations identified in this study.

“…Recognizing the particular needs of rural residents with opioid‐affected births can inform clinical and policy responses within the rural context, where resources, infrastructure, and health care workforce capacity differ substantially from urban areas . For instance, access to hospital‐based obstetric care is declining in rural United States counties; currently, fewer than half of rural counties have a hospital that provides obstetric services .…”

mentioning

confidence: 99%

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

The Journal of Rural Health

Chantarat

Ecklund

et al. 2018

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Purpose Opioid use disorder (OUD) during pregnancy is associated with poor maternal and infant outcomes, including neonatal abstinence syndrome (NAS), and both maternal OUD and NAS are increasing disproportionately among rural residents. This study describes the trajectory and characteristics associated with diagnosis of maternal OUD or NAS among rural residents who gave birth at different types of hospitals based on rural/urban location and teaching status. Methods Hospital discharge data from the all‐payer National Inpatient Sample were used to describe maternal OUD and infant NAS among rural residents from 2007–2014. Hospitals were categorized as rural, urban teaching, and urban nonteaching. We estimated incidence trends by hospital categories, followed by multivariable logistic regression analyses to identify correlates of OUD and NAS among rural residents, stratified by hospital category. Findings Incidence of maternal OUD increased in all hospital categories, with higher rates (8.9/1,000 deliveries) among rural residents who gave birth at urban teaching hospitals compared with those who gave birth at rural hospitals (4.3/1,000 deliveries) or urban nonteaching hospitals (3.6/1,000 deliveries; P < .001). A similar pattern was observed for infant NAS. In multivariable models, the association between maternal OUD and infant NAS diagnoses and hospital category differed by rurality (micropolitan vs. noncore.) Conclusions There has been a sustained increase in both maternal OUD and NAS diagnoses among rural residents. Measured sociodemographic and clinical correlates of maternal OUD and NAS differ by hospital category, indicating variability across hospital locations in patient populations and clinical needs for rural residents with these conditions.