Assessing the relationship between census tract rurality and severe maternal morbidity in California (1997‐2018)

Author:

Berkowitz Rachel L.1ORCID,Kan Peiyi2,Gao Xing3ORCID,Hailu Elleni M.3,Board Christine4,Lyndon Audrey5,Mujahid Mahasin3,Carmichael Suzan L.26

Affiliation:

1. Department of Public Health and Recreation College of Health and Human Sciences San José State University San Jose California USA

2. Department of Pediatrics (Neonatology) Stanford University School of Medicine Stanford California USA

3. Division of Epidemiology, School of Public Health University of California Berkeley California USA

4. Division of Research Kaiser Permanente Northern California Oakland California USA

5. Rory Meyers College of Nursing New York University New York New York USA

6. Department of Obstetrics and Gynecology (Maternal and Fetal Medicine) Stanford University School of Medicine Stanford California USA

Abstract

AbstractPurposeRecent studies have demonstrated an increased risk of severe maternal morbidity (SMM) for people living in rural versus urban counties. Studies have not considered rurality at the more nuanced subcounty census‐tract level. This study assessed the relationship between census‐tract‐level rurality and SMM for birthing people in California.MethodsWe used linked vital statistics and hospital discharge records for births between 1997 and 2018 in California. SMM was defined by at least 1 of 21 potentially fatal conditions and lifesaving procedures. Rural‐Urban Commuting Area codes were used to characterize census tract rurality dichotomously (2‐category) and at 4 levels (4‐category). Covariates included sociocultural‐demographic, pregnancy‐related, and neighborhood‐level factors. We ran a series of mixed‐effects logistic regression models with tract‐level clustering, reporting risk ratios and 95% confidence intervals (CIs). We used the STROBE reporting guidelines.FindingsOf 10,091,415 births, 1.1% had SMM. Overall, 94.3% of participants resided in urban/metropolitan and 5.7% in rural tracts (3.9% micropolitan, 0.9% small town, 0.8% rural). In 2‐category models, the risk of SMM was 10% higher for birthing people in rural versus urban tracts (95% CI: 6%, 13%). In 4‐category models, the risk of SMM was 16% higher in micropolitan versus metropolitan tracts (95% CI: 12%, 21%).ConclusionThe observed rurality and SMM relationship was driven by living in a micropolitan versus metropolitan tract. Increased risk may result from resource access inequities within suburban areas. Our findings demonstrate the importance of considering rurality at a subcounty level to understand locality‐related inequities in the risk of SMM.

Funder

National Institute of Nursing Research

Publisher

Wiley

Subject

Public Health, Environmental and Occupational Health

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