Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA.
Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, OH, USA.
BMC Public Health. 2020 Sep 22;20(1):1440. doi: 10.1186/s12889-020-09540-5.
Adequacy of prenatal care is associated with fulfillment of postpartum sterilization requests, though it is unclear whether this relationship is indicative of broader social and structural determinants of health or reflects the mandatory Medicaid waiting period required before sterilization can occur. We evaluated the relationship between neighborhood disadvantage (operationalized by the Area Deprivation Index; ADI) and the likelihood of undergoing postpartum sterilization.
Secondary analysis of a single-center retrospective cohort study examining 8654 postpartum patients from 2012 to 2014, of whom 1332 (15.4%) desired postpartum sterilization (as abstracted from the medical record at time of delivery hospitalization discharge) and for whom ADI could be calculated via geocoding their home address. We determined the association between ADI and sterilization completion, postpartum visit attendance, and subsequent pregnancy within 365 days of delivery via logistic regression and time to sterilization via Cox proportional hazards regression.
Of the 1332 patients included in the analysis, patients living in more disadvantaged neighborhoods were more likely to be younger, more parous, delivered vaginally, Black, unmarried, not college educated, and insured via Medicaid. Compared to patients living in less disadvantaged areas, patients living in more disadvantaged areas were less likely to obtain sterilization (44.8% vs. 53.5%, OR 0.84, 95% CI 0.75-0.93), experienced greater delays in the time to sterilization (HR 1.23, 95% CI 1.06-1.44), were less likely to attend postpartum care (58.9% vs 68.9%, OR 0.86, CI 0.79-0.93), and were more likely to have a subsequent pregnancy within a year of delivery (15.1% vs 10.4%, OR 1.56, 95% CI 1.10-1.94). In insurance-stratified analysis, for patients with Medicaid, but not private insurance, as neighborhood disadvantage increased, the rate of postpartum sterilization decreased. The rate of subsequent pregnancy was positively associated with neighborhood disadvantage for both Medicaid as well as privately insured patients.
Living in an area with increased neighborhood disadvantage is associated with worse outcomes in terms of desired postpartum sterilization, especially for patients with Medicaid insurance. While revising the Medicaid sterilization policy is important, addressing social determinants of health may also play a powerful role in reducing inequities in fulfillment of postpartum sterilization.
产前保健的充分性与产后绝育要求的满足有关，尽管尚不清楚这种关系是否表明健康的更广泛社会和结构性决定因素，还是反映了进行绝育之前所需的强制性医疗补助等待期。我们评估了邻里贫困（通过区域剥夺指数来体现；ADI）与产后绝育可能性之间的关系。
对 2012 年至 2014 年间的 8654 名产后患者进行了一项单中心回顾性队列研究的二次分析，其中 1332 名（15.4%）患者在产后希望进行绝育（从分娩住院出院时的医疗记录中摘录），并且可以通过对其家庭住址进行地理编码来计算 ADI。我们通过逻辑回归和 Cox 比例风险回归确定了 ADI 与绝育完成率、产后就诊率和产后 365 天内再次怀孕之间的关联。
在纳入分析的 1332 名患者中，居住在贫困程度较高的社区的患者更年轻、生育次数更多、经阴道分娩、为黑人、未婚、未受过大学教育且通过医疗补助保险。与居住在贫困程度较低地区的患者相比，居住在贫困程度较高地区的患者更不可能进行绝育（44.8%比 53.5%，OR 0.84，95%CI 0.75-0.93），绝育时间延迟更大（HR 1.23，95%CI 1.06-1.44），更不可能接受产后护理（58.9%比 68.9%，OR 0.86，CI 0.79-0.93），且产后一年内再次怀孕的可能性更高（15.1%比 10.4%，OR 1.56，95%CI 1.10-1.94）。在保险分层分析中，对于医疗补助而非私人保险的患者，随着邻里劣势的增加，产后绝育率下降。对于医疗补助和私人保险的患者，随后怀孕的几率与邻里劣势呈正相关。
居住在邻里劣势较大的地区与理想的产后绝育结果较差有关，尤其是对于拥有医疗补助保险的患者。虽然修订医疗补助绝育政策很重要，但解决健康的社会决定因素也可能在减少产后绝育实施方面的不平等方面发挥强大作用。
