(568) Association Between Maternal Care Deserts and Adverse Maternal Outcomes in Term Pregnancies Across US Counties

Maternal care access (MCA) continues to decline in the United States (US) with maternal care deserts expanding. Lower maternal care is a known risk factor for maternal morbidity but the association between maternal care deserts and adverse maternal outcomes has been inadequately studied at the county level. 


 

Study Design:

This was a retrospective cohort study using CDC birth certificate data from 2019-2021. Singleton, non-anomalous, live births from 37- 42 weeks were included. Using 2020 March of Dimes Maternal Care Access Report county data, MCA was classified as full, moderate, low or a desert based on county level access to hospitals providing obstetric care, number of obstetric providers per 10,000 births and percent of women without health insurance. The primary outcome was a composite maternal adverse outcome (CMAO) that included transfusion, unplanned hysterectomy, ruptured uterus and admission to the intensive care unit (ICU). Multivariable logistic regression models were used to estimate the association between MCA level and the CMAO and adjusted for both clinical risk factors and county level access to resources using the CDC’s Social Vulnerability Index.

Results:

There were 3,137 counties and 1,099 (35%) were in maternal care deserts. Of the 9,226,640 pregnancies that met inclusion criteria 1,108,385 (12.0%) were in counties without full MCA, including 372,216 (4.0%) in maternal care deserts. The CMAO was elevated in maternal care deserts even after controlling for individual and county level factors (aRR 1.71:  95% CI 1.63-1.79) when compared to counties with full MCA. This was driven by increased rates of transfusion (aRR 2.26: 95% CI 2.14-2.39) and unplanned hysterectomy (aRR 1.32: 95%CI 1.09-1.58). There was no difference in uterine rupture (aRR 0.86: 95% CI 0.70 -1.06) or ICU admission (aRR 0.92: 95% CI 0.82-1.03).

 

Conclusion:

One in 25 pregnancies are delivered in maternal care deserts and these births are associated with increased rates of maternal morbidity. This suggests that further reduction in MCA may be associated with increased risk of maternal morbidity and mortality.