Kozhimannil Katy B, Casey Michelle M, Hung Peiyin, Prasad Shailendra, Moscovice Ira S
University of Minnesota Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health.
University of Minnesota Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health.
Am J Obstet Gynecol. 2016 May;214(5):661.e1-661.e10. doi: 10.1016/j.ajog.2015.11.030. Epub 2015 Dec 2.
A recent American Congress of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine (MFM) 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.
We sought to characterize rural women who give birth in nonlocal hospitals and measure local hospital characteristics and maternal diagnoses present at childbirth that are associated with nonlocal childbirth.
This was a repeat cross-sectional analysis of administrative hospital discharge data for all births to rural women in 9 states in 2010 and 2012. Multivariate logistic regression models were used to predict the odds of childbirth in a nonlocal 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 MFM consultation), as well as local hospital characteristics (birth volume, neonatal care level, ownership, accreditation, and system affiliation).
The rate of nonlocal childbirth among 216,076 rural women was 25.4%. It varied significantly by primary payer (adjusted odds ratio [AOR], 0.76; 95% confidence interval [CI], 0.68-0.86 for Medicaid vs private insurance) and by clinical conditions including multiple gestation (AOR, 1.82; 95% CI, 1.58-2.1), preterm deliveries (AOR, 2.41; 95% CI, 2.17-2.67), and conditions that may require MFM services or consultation (AOR, 1.28; 95% CI, 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 nonlocal hospital (AOR, 1.94; 95% CI, 1.64-2.31).
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 nonlocal hospitals. However, after controlling for clinical complications, rural Medicaid beneficiaries were less likely to give birth at nonlocal hospitals, implying a potential access challenge for this population.
美国妇产科医师大会和母胎医学协会（MFM）近期关于产科护理水平的共识声明列出了与提供产科护理的机构所具备的特定能力相对应的分类。在区域化和护理水平的讨论中，农村和偏远地区的孕妇受到特别关注，因为在必要时确保当地能够获得高 acuity 服务存在挑战。目前，美国医院每年约有 50 万农村妇女分娩，这些妇女是否以及哪些在当地分娩对于成功实施孕产妇护理水平至关重要。
我们试图描述在外地医院分娩的农村妇女的特征，并衡量与外地分娩相关的当地医院特征和分娩时的孕产妇诊断。
这是对 2010 年和 2012 年 9 个州农村妇女所有分娩的医院行政出院数据进行的重复横断面分析。使用多变量逻辑回归模型预测在外地医院（距离患者居住地至少 30 英里）分娩的几率。我们研究了患者年龄、种族/族裔、付款人、农村地区、临床诊断（糖尿病、高血压、孕期出血、胎盘异常、胎位异常、多胎妊娠、早产、既往剖宫产以及可能需要 MFM 会诊的诊断组合），以及当地医院特征（分娩量、新生儿护理水平、所有权、认证和系统隶属关系）。
216,076 名农村妇女中的外地分娩率为 25.4%。按主要付款人（调整后的优势比[AOR]，0.76；95%置信区间[CI]，医疗补助与私人保险相比为 0.68 - 0.86）以及包括多胎妊娠（AOR，1.82；95%CI，1.58 - 2.1）、早产（AOR，2.41；95%CI，2.17 - 2.67）和可能需要 MFM 服务或会诊的情况（AOR，1.28；95%CI，1.22 - 1.35）在内的临床状况，该比率有显著差异。当地医院没有新生儿重症或中级护理单元的农村妇女在外地医院分娩的几率几乎翻倍（AOR，1.94；95%CI，1.64 - 2.31）。
约 75%的农村妇女在当地医院分娩；早产和有临床并发症的农村妇女，以及当地无法获得更高 acuity 新生儿护理的妇女，更有可能在外地医院分娩。然而，在控制临床并发症后，农村医疗补助受益妇女在外地医院分娩的可能性较小，这意味着该人群可能存在就医机会方面的挑战。
