Race and Place: An intersectional approach to maternal health inequities and healthcare systems factors in the Rural South

项目摘要/摘要：本项目是对特别强调通知（SEN）NOT-HS-21-014的回应， 对卫生服务研究的兴趣，以促进健康公平。产妇发病率的负担 1）黑人，西班牙裔和土著生育者和2）生活在农村地区的人不成比例 在美国严重孕产妇发病率（SMM）在很大程度上是可以预防的， 产妇死亡率，并有其自身深远的健康后果。关于种族和农村问题的最新研究 SMM中的差异忽略了一个重要的事实：不同种族和民族的农村人生活在不同的环境中， 因此，在获得医疗保健服务方面可能存在差异。种族构成 黑人居民占中西部和东北部农村人口的1- 3 但在南方只有20-40%。即使在南部，像阿巴拉契亚这样的地区也有超过90%的白色，而在黑带地区， 包含黑人超过50%的县。以前的研究发现，基础设施更差，整体水平更低 健康，以及黑带居民的早期死亡率，尽管产妇的结果还没有得到 评估。要真正采取跨部门办法解决与农村和种族有关的不平等问题， 考虑到农村人口居住的地理环境。该提案纳入了交叉性， 包括县的种族组成作为背景因素来描述北方农村SMM的分布， 卡罗莱纳（北卡罗来纳州）。该提案还旨在通过审查医疗保健来超越描述健康差异 系统因素可能因县的种族组成而异，并有助于SMM。这项研究将采样 NC农村人口。主要数据源将是与医疗补助申请相关的出生证明， 确定SMM，但也将利用公共和机构提供的数据进行全面评估。 目标1将使用县的种族组成的五分位数，可操作为非西班牙裔白人的比例 (NHW)在每个县，描述1）SMM在非西班牙裔白色，非西班牙裔黑人， 西班牙裔和农村县的土著居民和2）医疗保健系统因素。这些因素包括： 产科单位的存在、提供者组合、医院床位数量、医院类型、医院服务，以及 分娩中心的存在。目标2将评估产科病房关闭的影响（已知集中在 在居民主要是黑人或土著人的地区）， 西班牙裔白人（高NHW）与低比例的非西班牙裔白人（低NHW）。最后，Aim 3将使用 分解的方法来估计联合差距在SMM有关的社会地位的种族和 县的种族组成的社会背景，以确定在何种程度上， 制度因素解释了这种联合差距。拟议的研究将描述与农村有关的差距 和种族的交叉框架，并阐明哪些卫生保健系统的因素可能会促进公平 对于这些人群。

Project Summary/ Abstract: This project is responding to Special Emphasis Notice (SEN) NOT-HS-21-014, Interest in Health Services Research to Advance Health Equity. The burden of maternal morbidity is borne disproportionately by both 1) Black, Hispanic and Indigenous birthing people and 2) people living in rural areas in the United States. Severe maternal morbidity (SMM) is largely preventable, contributes significantly to maternal mortality, and has its own far-reaching health consequences. Recent research on racial and rural disparities in SMM misses an important fact: rural people of different races and ethnicities live in different geographic contexts and may therefore have differential access to healthcare services. The racial composition of rural counties varies widely: Black residents are 1-3% of the rural population in the Midwest and Northeast but 20-40% in the South. Even within the South, areas like Appalachia are >90% White while the Black Belt contains counties that are over 50% Black. Previous research has found worse infrastructure, lower overall health, and earlier mortality among residents of the Black Belt, though maternal outcomes have not been evaluated. A truly intersectional approach to addressing disparities related to rurality and race requires considering the geographic context in which rural people reside. This proposal incorporates intersectionality by including racial composition of county as a contextual factor to describe the distribution of SMM in rural North Carolina (NC). The proposal also aims to go beyond describing health disparities by examining healthcare systems factors that may vary by racial composition of county and contribute to SMM. This study will sample from a rural NC population. The primary data source will be birth certificates linked to Medicaid claims, ideal for identifying SMM, but will also leverage publicly and institutionally available data for comprehensive evaluation. Aim 1 will use quintiles of racial composition of county, operationalized as proportion of Non-Hispanic Whites (NHW) in each county, to describe the distribution of 1) SMM among Non-Hispanic White, Non-Hispanic Black, Hispanic, and Indigenous residents of rural counties and 2) healthcare systems factors. These factors include: presence of an obstetric unit, provider mix, number of hospital beds, hospital type, hospital services, and presence of birthing center. Aim 2 will evaluate the impact of obstetric-unit closures (known to be concentrated in areas where residents are predominantly Black or Indigenous) in counties with high proportions of Non- Hispanic Whites (high NHW) vs. low proportions of Non-Hispanic Whites (low NHW). Finally, Aim 3 will use a decomposition approach to estimate the joint disparity in SMM related to the social status of race and the social context of racial composition of county to determine the extent to which the availability of healthcare systems factors explain this joint disparity. The proposed research will describe disparities related to rurality and race in an intersectional framework, and elucidate which health care systems factors may advance equity for these populations.