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Today we are going to hear from Dr. Maggie Thorsen from Montana State University. In today's talk, she's going to be presenting research on access to obstetric health care in Montana. In this work, Dr. Thorsen and her colleagues used birth certificate data from 2014 to 2018 to examine variation in drive times to give birth at hospitals across Montana. The results of this research provides important data on access to obstetric care in the state, and highlights disparities in access for particular populations in Montana. This work draws attention to the importance of facility level infrastructure to connect patients to care particularly complex obstetric care. Doctor Thorsen joined the faculty at Montana State in 2014 and is an associate or as an assistant professor of sociology and the Department of Sociology and Anthropology. Maggie's research aims to better understand factors contributing to the health and well being of families including equity and access to health care. She is especially interested in understanding how people experience inequity in accessing healthcare and identifying characteristics of healthcare operations that might help improve health care access and decrease health disparities. So thank you so much for being with us today, Maggie, and I'm just gonna let you take it away. Alright, so thank you so much to Anna and everyone else who's joining us today. I'm really excited to be able to share our research and data with this audience, so I look forward to any feedback or comments that you might have about this work. Would love to chat with you, so I first like to thank my co- authors on this project, Andreas Thorsen and Sean Harris from Montana State University. Janelle Palacios from the Department of Obstetrics and Gynecology at Kaiser Permanente, North Carolina and Ron McGarvey from the University of Missouri. So the data that I'm presenting today is part of a study that was recently published in the Journal of Rural Health. So as we know, the health and well being of mothers and infants are really important as they impact the health of individuals, families and communities both now and into the future. So in the United States, unfortunately. Oh excuse me, can you not hear me? Sorry, I heard someone say something anyway, so in the United States, unfortunately maternal and infant health outcomes are considered generally poorer than in similarly industrialized countries, so birth outcomes such as rates of premature birth and low birth weight births are significantly higher in the United States then in other countries. We also see that the United States is one of the highest infant mortality rates in the developed world, as we see in this graphic. Significantly higher than many other countries. Uhm, looking at maternal mortality in particular, we see that the United States is really not doing so well. Nearly 700 women die each year due to pregnancy related complications, and 50,000 women suffer from life threatening pregnancy related complications, of which 60% are preventable. And this problem appears to be growing. the United States is the only nation in the developed world that has a rising maternal mortality rate, and we can see this in this graphic as well, really stark comparisons. Now these issues of poor maternal and infant health are even more pronounced for racial and ethnic minority women, so in particular we see for African American and American Indian and Alaskan Native women that these women and their infants experience higher rates of low birth weight births, preterm births, as well as infant mortality, and maternal mortality compared to women from other racial and ethnic groups, and in particular compared to non Hispanic white women. So here we see that the in particular the infant mortality rate for black and American Indian women, as well as Native Hawaiian, other Pacific Islander women in the United States are over twice that of white women. Turning to maternal mortality, we see that black and American Indian and Alaska Native women are between two and five times more likely to die from a pregnancy related complication compared to white women. We also see racial and ethnic disparities in other birth outcomes related to infant health. So in this graphic I'm showing you the percentage of live births that are born preterm, and here again we see that American Indian women and black women have significantly higher rates of preterm birth compared to other racial and ethnic groups. So these patterns of maternal and infant health are mirrored in Montana, where we see higher rates of poor maternal and infant health outcomes among our indigenous women in Montana compared to white women. Now the root cause of these health disparities is complex and multifaceted, but in the face of these poor maternal and infant health, health care remains an important point of contact for mothers and babies during the prenatal delivery and postpartum period. So when thinking about health care, we can think about access and quality as two major issues that affect and shape how clinicians are able to interact with mothers and these babies and babies and potentially positively impact maternal and infant health outcomes. Access and quality are interrelated acts, aspects of health care where having access to the right kind of care at the right time is a key component of quality. Additionally, there are other factors, and the intersection of these factors that might impact the need for, the access to, the quality, and the outcomes of maternity care. So these can be things like clinical conditions, health insurance coverage, morality and sociodemographic characteristics, including race and ethnicity. Now, neither access nor quality, access to care and or high quality care alone is going to ensure good outcomes in childbirth, but rather the combination of timely access, an appropriate quality care is necessary for effective maternity care. And because the access and quality interact, and because different factors impact both access and quality, the solutions to improving access and quality have to be multifaceted and are going to dramatically differ depending on geography. So in our research we focus a lot on inequities in access for women across the intersections of race and morality. Now when we're talking about maternity care and obstetric care it's important to kind of understand what that scope of care might be. So maternal level of care designations are a common metric that's used to classify the availability of obstetric care services at a particular facility. The American College of Obstetricians and Gynecology points to these maternal level of cares and says that the goal of these of maternal care is to reduce maternal mortality and morbidity, including existing disparities in these and to encourage the growth and maturation of systems for the provision of risk appropriate care that's specific to maternal health needs. So these designations help us to identify what services exist at a given facility so that we might be able to connect patients and who have particular health needs with the appropriate level of care. So using a specific set of criteria and measures and metrics, hospitals that have obstetric units are designated as falling into one of four levels depending on factors such as staffing, equipment, and the availability of services and procedures. And so we see these as Level 1 of providing sort of basic obstetric care that provide the needed obstetric care for most women who give birth in the United States who have few pregnancy risks. Level 2 involves more specialty care and for women who have more complex and high risk pregnancies and conditions there might be a benefit in accessing services available through specialty and even subspecialty care. So for example, Level 2 specialty care differs from a Level 1 obstetric unit and then includes access to certain personnel such as consultation with a fetal medicine, maternal fetal medicine specialists, having an anesthesiologist that specializes in obstetric anesthesia, having an OBGYN on site at all times and having more advanced equipment such as imaging equipment and the equipment available to conduct amniotic fluid analysis. Level 3 takes it a step above Level 2 and includes more advanced training for personnel, including having an on site maternal fetal medicine specialist, and even more advanced equipment, and as well as the ability to perform more complex procedures and advanced therapies. Now it's important to note that in Montana this final level, Level 4 doesn't exist. We do not have a Level 4 facility in this site, which is this regional perinatal health care center. But these health care centers are equipped with staff and equipment to perform all of the other services at these lower levels, as well as having more surgical specialists on site. In our research, we've designated hospitals as being Level 0 if they do not have an obstetrics unit. And within our data set, we see that births that have occurred over this five year period occurred at seven Level 0 hospitals, 18 Level 1 hospitals, seven Level 2 hospitals, and three Level 3 hospitals. So these services right depending on the facility that women are going to there are different levels of care and different kinds of procedures that they have access to. So that's kind of a more complex understanding of what obstetric care might look like but when we think about actual access to care in general, this story of access to obstetrics care in the United States isn't really good. 2.2 million childbearing aged women live in maternity care deserts, which are counties that are do not have any obstetric services. Another 4.8 million women live in counties that have limited access to maternity care. And this story is particularly bad in rural areas. So across rural areas of the U.S. access to obstetric services is actually declining with 9% of rural counties having lost access to services between 2004 and 2014. And since 2010, about 100 rural hospitals have closed further limiting access. We also know that workforce shortages are really important issues. Issues and decline in the number of OBGYN's in general practice and other birth workers, it's really bad in in rural areas and especially in the Mountain West. So why does access matter? Well, research suggests that reductions in access to hospital based obstetrics is linked to increases in poor birth outcomes in rural areas, including things like rates of preterm births. And what's interesting is that these loss of obstetric services appear to be especially problematic in rural areas where having lost that services is associated with a greater increase in kind of poor outcomes for rural spaces compared to more urban areas. And this is troubling given that rural areas already have higher rates of poor birth outcomes, including things like infant mortality rate, preterm births and lower birth weight births. Now this poor access to obstetric care in rural places, as part of a larger story in rural America. Rural areas have poor access to healthcare and scarcity of services might be exacerbated by different cultural and financial constraints that reduce that might reduce health care seeking behavior. So women living in rural and geographically isolated areas often travel long distances to obtain goods and services, including obstetric care. Uhm, just 28% of reproductive age women who live in remote areas live within 1/2 an hour drive of hospital based obstetric services. This is compared to 77% of women living in micropolitan areas and 93% of women in living in metropolitan areas. So women living in rural spaces don't live very close to obstetric services and previous research at a national level has actually identified Montana as having some of the poorest access to obstetric services in terms of our long drive times. And this lack of services within a reasonable travel time imposes a barrier to care when women lived rurally. Now for rural American Indian women, these barriers to care might be further compounded by issues such as high poverty rates, longer distances to available services that might be covered through American Indian Services funded programs, and in general research has found that access to obstetric care is worse for rural racial minorities. And these racial disparities in health care access appear more severe in rural areas than in urban areas, including things like access to providers, the procedures that women receive and the travel time to health care. However, there's been very little attention to the experience of the American Indian population, which is an important oversight and something that our research tries to do. Now, despite the longstanding federal government legal obligations to provide health care access to American Indian people, health services for this population is chronic or chronically underfunded. We also see that research and research that American Indian women, we consistently find that American Indian women have higher rates of inadequate prenatal care. So, for example, about 33% of American Indian women enter into prenatal care late, whereas compared to only 13% of white women. In addition, 45% of American Indian women are said to have inadequate prenatal care compared to only 24% of white women. So right we see these higher rates of access or poor access and poor care. Now for Montana reservation dwelling American Indian women who might be served by IHS or other facilities, there might be a number of barriers to accessing care which might include their remote proximity to obstetric services, shortages in clinicians, a lack of provider continuity. Just a general limited availability of maternal health services, various communication barriers, financial burdens, transportation barriers and so on. And beyond geographic access to services American Indian women may lack access to health care that is considered culturally safe or defined as a patient centered, culturally congruent care that can improve the provision of care and patient health outcomes. So these issues of access to obstetric care exist at the same time that we see poor maternal and infant health outcomes for native women. So we see higher poor birth outcomes including low birth weight births, twice the odds of preterm delivery compared to white women almost twice the odds of infant mortality and four times the odds of maternal mortality. So remote American Indian women might simultaneously need to drive further to access obstetric services, and especially higher level specialty care compared to white counterparts while also experiencing higher risk of poor birth outcomes and therefore a greater need for those specialty care. So when we talk about what equity and access really means, equity in access might be said to exist when services are distributed on the basis of people's need for them, and so this scenario where American Indian women have few services available to them, but the greatest need for them really epitomizes healthcare inequity. So this is what our research seeks to examine. So we want to examine these issues of access to obstetric care in Montana, and our project is entitled, "Modeling Rural Perinatal Health Outcomes and Service Systems to Improve Health Equity" and this is funded through the Center for American Indian and Rural Health Equity at Montana State. And so in this research that I described today, we're using data from five years of birth certificates between 2014 and 2018 with a sample of over 50,000 hospital based births to mothers who resided in Montana at the time of the birth. Additionally, we use data on Montana hospitals from the 2018 survey of the American Hospital Association. So in our research we wanted to identify and understand both the potential access that was available to women in Montana or the supply of existing services, as well as how that access was then realized through the utilization of services. So to measure supply we developed what are called coverage models and this helps to identify the proportion of pregnant women who lived within a one hour and 2 hour drive time of a particular hospital facilities. Now one hour drive time is approximately the furthest people might be inclined to travel for specialty healthcare and it has been shown to be the farthest safe drive time for maternity patients. However, given that the focus our focus is in Montana, which is a very rural state with some extreme travel times, we also wanted to identify women within two hour drive times. So these coverage models help us to see the potential access that women might have to hospital based obstetric services and to specific levels of maternal obstetric care and those more complex services. To measure utilization of services, we calculated the actual time that women had to drive to give birth. So using information on the residential ZIP code and the location of their birth facility, we could then calculate how long they drove to give birth. So in our research we generated a series of maps to help us to understand what this access looks like in Montana. So I want to point out a few things in these maps. First, these dots represent the hospital facilities that exist in Montana. The blue dots represent those at the Level 3 the most complex subspecialty care, orange is Level 2, yellow is Level 1 and pink are these Level 0 facilities that don't have an obstetric unit. We notice that our American Indian reservations are outlined in red, and these color gradations of the top maps indicate drive time or and then the bottom maps indicate the average number of births. So looking at our map in the top left, what we see is that approximately 24% of all zip codes that women live in are more than three hours away from from a Level 3 facility. So a quarter of a place of ZIP codes, people or three hours away from these high levels of complex care and this represents about 9% of all births. And now, while most women in Montana lived closer to hospitals that have an obstetric unit, so at least a Level 1 unit or higher, in this top right map we see that about 40% of ZIP codes are more than an hour away from any facility with an obstetric unit, which represents about 12% of total births. Now looking at our bottom two maps, we see that facilities that can handle more complicated births, so these Level 2 and Level 3 facilities generally align well with counties that have more births, but generally align more with those counties that have more white births. As we can see in these comparisons of the average number of white births and the average number of American Indian births. We also wanted to examine the proximity that women lived to potential birth facilities and here we found that while the majority of white women lived with and out within a one hour drive of a Level 2 facility, only a quarter of American Indian women lived within a one hour drive of a Level 1 facility. Looking at Level 3 facilities, we again see that white women were much more likely to live close by to a Level 3 facility or within a one hour drive compared to American Indian women. We also find that in terms of potential access, that rural women would need to travel significantly further to access facilities that have a higher level of obstetric care. Now here when we look at actual utilization, we can see a few things. First, we note that American Indian women are more likely to give birth to actually use a facility that provides a basic level of care, this Level 1 obstetric facility. So 43% of American Indian women give birth at a Level 1 facility, compared to only 18% of white women. White women, on the other hand, are more likely to give birth at a Level 2 facility, so 42% of white women give birth at a Level 2 compared to only 24% of American Indian women. These differences are narrower for Level 3 facilities, we're right at 35% of white women give birth at a Level 3 compared to 30% of American Indian women. Looking at our Level 0 facilities or those hospitals that do not have an obstetric unit, we do see that very few women give birth at these hospitals but American Indian women are much more likely to give birth at a hospital that lacks an obstetric unit. In fact, the American Indian women are over 20 times more likely to give birth at a hospital that lacks an obstetric unit. When we look at morality, we see that births to women living in more populated counties are more likely to occur at these Level 2 and Level 3 facilities, which is where they're located. Whereas women in these rural counties are not likely to give birth at these with the places with higher levels of care. In terms of realized access or utilization, our results suggest that drive time to give birth varied among women, especially by their level of morality and where they lived, and also their racial identity. Now, on average, women travelled about 42 minutes from their home to give birth, but about 20% of women drove over an hour and some women driving upwards of 10 hours to give birth and of course morality is associated with travel times. And as we see as people, the more rural these places are, the longer women are driving. So we measured morality using what's called the Rural Urban Continuum Code which captures both the population size of an area as well as its remoteness or adjacency to a metro area. When we look at the intersection of morality and race, we see that American Indian women in these orange bars tended to travel significantly further to give birth, even when compared to women to white women living in similarly rural areas. Now our data also suggests that racial disparities in access are even more pronounced when we look at access to hospitals that provide more advanced specialized care so these Level 2 or 3 hospitals. A smaller percentage of American Indian women gave birth at these higher level facilities compared to white women even those living in similarly rural areas. And in terms of potential access, pregnant American Indian women would have had to travel significantly further to access these higher level facilities compared to America to white women. We also examined how this issue of reduced access to complex care worked when looking at women who would actually need those more advanced obstetric care. So there are various factors that increase risk in pregnancy and might necessitate a more complex specialty care such as preeclampsia or gestational diabetes. In our sample, 33% of American Indian were diagnosed with one or more pregnancy health risk factor compared to 27% of white women. And when we focus on just those women who have a pregnancy risk factor, we find an American Indian women with pregnancy risk lived further away from higher levels of tears and white women even when they lived in similarly rural areas. So and considering actual utilization, the same high risk pregnant American Indian women were less likely than white women to give birth at a higher level facility, right? So these American Indian women who had a risk factor, only 58% of them gave birth at a facility that had higher level of care compared to 81% of white women. Now these issues of access to complex obstetric care are especially pronounced for women living on Montana reservations, so here we see that women living on reservations or these orange bars traveled significantly further to access obstetric care, but especially higher levels of obstetric care, right to access a Level 2 facility women living on reservations or traveling over 2 hours compared to women living off reservation. So in conclusion, our data points to rural and racial disparities in access and utilization of obstetric care in Montana. American Indian women travel further to access obstetric care even compared to women, white women living in similarly rural spaces. And these longer drive times among American Indian women are explained in part by the rurality of where they live as well as their residence on reservations. Our results also suggests that rural American Indian women are traveling farther than their white counterparts, in part because they're traveling further to access these higher levels of obstetric care, and this again is especially pronounced on reservations. So this data has implications for health care policy in the state. Currently, there's legislation that's working to designate areas of the country as places that have limited obstetric care and part of implementing the Improving Access to Maternity Care Act involves distributing maternity care professionals to these shortage areas using an award awarding mechanism and our results point to the challenge of distributing professionals to areas in need if there are no obstetric units and where infrastructure might not be sufficient to provide complex care for high risk births. So even with policy efforts to increase the number of professionals in underserved areas, which is something we all know is needed, our findings suggests that racial disparities in access to especially complex obstetric care will persist unless these facility level infrastructures are also expanded to reach these areas that serve our American Indian populations. Thank you so much for your time and attention to my talk. If any of you have any kind of comments or questions, I am very happy to hear from you or if you would like to hear more about the work we're doing. Please reach out and contact me. Thank you so much.