Severe Maternal Morbidity and Mortality Risk at the Intersection of Rurality, Race and Ethnicity, and Medicaid

Interrante, Julia D.; Tuttle, Mariana S.; Admon, Lindsay K.; Kozhimannil, Katy B.

doi:10.1016/j.whi.2022.05.003

Cited by 19 publications

(19 citation statements)

References 30 publications

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“…Medicaid finances 41% of births in the United States, 2 and a disproportionate number of births to individuals with the greatest risk of incurring SMM and mortality, including non-Hispanic Black and Indigenous individuals, rural residents, and those living in lower income ZIP codes. 3 Many state Medicaid programs are pursuing clinical interventions and health policies designed to address the high rates of SMM and maternal health equity in the United States. [4][5][6][7] To date, however, there has been a lack of comprehensive surveillance data on health outcomes, including SMM, among individuals with Medicaid insurance to inform these decisions.…”

Section: Resultsmentioning

confidence: 99%

State Variation in Severe Maternal Morbidity Among Individuals With Medicaid Insurance

Admon

Auty

Daw

et al. 2023

Obstetrics &Amp; Gynecology

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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.

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Section: Resultsmentioning

confidence: 99%

State Variation in Severe Maternal Morbidity Among Individuals With Medicaid Insurance

Admon

Auty

Daw

et al. 2023

Obstetrics &Amp; Gynecology

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“…In addition to investments in critical access obstetrics in rural communities and to clinical care and support, policy attention to the broader social determinants of maternal and infant health in remote, rural communities is important . In particular, attention to the intersection of structural racism and structural urbanism requires investment in rural communities with substantial Black and Indigenous populations, where maternal health risks are most acute and access to obstetric care is most limited …”

Section: Discussionmentioning

confidence: 99%

Obstetric Volume and Severe Maternal Morbidity Among Low-Risk and Higher-Risk Patients Giving Birth at Rural and Urban US Hospitals

et al. 2023

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ImportanceIdentifying hospital factors associated with severe maternal morbidity (SMM) is essential to clinical and policy efforts.ObjectiveTo 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 ParticipantsThis 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.ExposuresAnnual birth volume categories (low, medium, medium-high, and high) for hospitals in urban (10-500, 501-1000, 1001-2000, and &gt;2000) and rural (10-110, 111-240, 241-460, and &gt;460) counties.Main Outcome and MeasuresThe 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.ResultsAmong 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 (&gt;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 RelevanceIn 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.

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“…This seems like a shortsighted criticism. Much evidence exists that race, gender and other social constructs correlate with medical and social outcomes (Interrante et al , 2022). Dismissing race as “merely” a social construct ignores the impact of the social in society.…”

Section: Genetic Testing and White Nationalismmentioning

confidence: 99%

The dangerous use of genetic information

Johnson,

Shaw

2023

JICES

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Purpose The purpose of this paper is to inform or alert readers to the extensive use and ready availability of genetic information that poses varying degrees of social and legal danger. The eugenics movement of the 1920s and the general acceptance of genetic essentialism provide context for considering contemporary examples of the problem. Design/methodology/approach This paper takes an argumentative approach, supporting proposals with ideas from historical and current research literature. Findings The limits of data protection, extensive use of direct-to-consumer genetic testing and use of genetic information in white nationalist circles portend a resurgence of eugenic beliefs from a century ago. Social implications Research-based recommendations may help to avoid extreme consequences by encouraging people to make informed decisions about the use of genetic information. Originality/value The paper counterposes contemporary understanding of genetic testing and data accessibility with the much older ideology of eugenics, leading to concerns about how white nationalists might further their aims with 21st century technology.

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Severe Maternal Morbidity and Mortality Risk at the Intersection of Rurality, Race and Ethnicity, and Medicaid

Cited by 19 publications

References 30 publications

State Variation in Severe Maternal Morbidity Among Individuals With Medicaid Insurance

State Variation in Severe Maternal Morbidity Among Individuals With Medicaid Insurance

Obstetric Volume and Severe Maternal Morbidity Among Low-Risk and Higher-Risk Patients Giving Birth at Rural and Urban US Hospitals

The dangerous use of genetic information

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