Developing Rural-Relevant Strategies to Reduce Maternal Morbidity
Most people enter pregnancy without anticipating major risks to their health. Yet every year, at least 50,000 experience potentially life-threatening complications of childbirth (e.g., blood clots, acute renal failure, shock, cardiac arrest, respiratory distress, amniotic fluid embolism, eclampsia, complications of anesthesia). The rate of severe maternal morbidity doubled between 1998 and 2011, as did maternal mortality, doubling between 1990 and 2013. In the general population, there are divergent morbidity trends in rural and urban areas, leading to excess mortality among rural residents. Both of these troubling trends render residents of rural areas particularly vulnerable to illness and death following childbirth.
Several national clinical efforts are underway to address severe maternal morbidity, but many national efforts do not address the specific conditions of care provided in rural contexts (e.g., limited access to specialty providers, lack of a dedicated operating room for obstetrics, use of general - vs. specialized - nursing staff in labor and delivery units). Attention to the particular challenges faced by rural patients and healthcare facilities is crucial to the success of efforts to reduce maternal morbidity and mortality in rural areas. Additionally, state and federal legislators have increasingly proposed and adopted policies in the wake of rising rates of maternal morbidity and mortality. Many policy efforts focus on the establishment of committees to review cases of maternal morbidity or mortality, and clinical leaders have argued for the importance of these efforts at federal, state, and local levels. As these efforts gain strength, it is not clear to what extent rural populations are recognized and explicitly included in policies designed to address this growing crisis. No prior studies have examined rural-urban differences in current trends in maternal morbidity. Such evidence is urgently needed to inform geographically-tailored clinical and policy efforts to reverse the rising rates of maternal morbidity and mortality nationally.
This project is national in scope and will have relevance for policy making at the federal, state, local, and institutional levels. We will conduct analyses using both a 20% sample of births (2004-2014) to assess trends and on a 100% sample of hospital-based 2014 births that occurred in 9 states across the four U.S. census regions. We also plan to conduct a review of state and federal legislation (including proposed legislation) related to maternal mortality and maternal morbidity review committees, as well as a site visit to a rural hospital providing obstetric services. The purpose of the visit is to discuss management of care during pregnancy and childbirth with clinicians and hospital administrators; how a high-risk designation affects care for rural residents (e.g., referrals to specialized or subspecialized care); and how decisions are made to transfer rural patients in the intrapartum period.