Rural–Urban Differences in Health Care Access Among Women of Reproductive Age: A 10-Year Pooled Analysis
Authors: Hyunjung Lee, Ching-Ching Claire Lin, John E. Snyder
Journal: Annals of Internal Medicine (2020)

Supplement1 December 2020Rural–Urban Differences in Health Care Access Among Women of Reproductive Age: A 10-Year Pooled AnalysisFREEHyunjung Lee, PhD, Ching-Ching Claire Lin, PhD, MHS, and John E. Snyder, MD, MS, MPHHyunjung Lee, PhDOak Ridge Institute for Science and Education, Oak Ridge, Tennessee (H.L.)Search for more papers by this author, Ching-Ching Claire Lin, PhD, MHSOffice of Planning, Analysis, and Evaluation, Health Resources and Services Administration Rockville, Maryland (C.L., J.S.)Search for more papers by this author, and John E. Snyder, MD, MS, MPHOffice of Planning, Analysis, and Evaluation, Health Resources and Services Administration Rockville, Maryland (C.L., J.S.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M19-3250 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: As reported in this journal supplement, U.S. maternal mortality rates are rising. The highly rural South experiences greater health workforce shortages and more maternal deaths annually than other regions, possibly driving national-level mortality increases. As the American College of Obstetricians and Gynecologists (ACOG) has reported, rural women less often receive reproductive health services and initiate prenatal care; have more unintended pregnancies, home-based births, and hospitalizations with pregnancy complications; and experience worse infant-related outcomes, including low birthweight and preterm birth (1). Rural women experience higher rates of poverty, Medicaid reliance, and uninsurance, and they more often receive delayed or no medical care because of costs and insurance access (1).Objective: To investigate rural–urban differences in health care access among women of reproductive age.Methods and Findings: Ten-year (2006 to 2015) pooled Medical Expenditure Panel Survey (MEPS) data were merged with 2010 rural–urban commuting area (RUCA) codes for women of reproductive age (15 to 44 years) for this analysis (N = 74 524). MEPS is possibly the most complete source of nationally representative survey data on health care costs, utilization, insurance coverage, and how individuals interact with the health care system. Six binary variables served as health care access measures: uninsured status, having a usual source of care, unmet care needs, delayed care, any physician visits, and any obstetrician-gynecologist visits during the past 12 months. Consistent with Health Resources and Services Administration (HRSA) policy for defining rurality, geographic tracts with RUCA codes between 4 and 10 were considered rural. RUCA codes consider work commuting information to characterize rural and urban status and rural–urban relationships within the nation's census tracts. Multivariable logistic models were estimated, controlling for selected variables that might confound associations between rurality and access to care (Table) (2). Survey design procedures accounted for the complex sampling of MEPS using Stata, version 15 (StataCorp). Marginal effects of rural residence were computed with delta method standard errors. Accounting for missing values, pooled sample sizes ranged from 51 336 to 52 190.Table. Baseline Characteristics and Outcome Measures, by Rural and Urban Residence*The Figure presents unadjusted 10-year trends by rural or urban residence for the 6 health care access outcomes studied. Rates of having visits with any physician and specifically obstetrician-gynecologists in the past 12 months were lower for rural women in nearly all study years. Over the entire study period, rural women were more likely to report poorer health status and lower income and education levels (Table). After adjustment, rural women were more likely to report having a usual source of care (4.9 percentage points [95% CI, 2.1 to 7.7 percentage points]) and slightly less likely to report having delayed care (−1.3 percentage points [CI, −2.5 to −0.2 percentage points]). No rural–urban differences were observed in reports of uninsured status (2.0 percentage points [CI, −0.2 to 4.1 percentage points]) and unmet care needs (−0.2 percentage points [CI, −1.1 to 0.8 percentage points]). However, rural women were overall less likely to report having had any physician visits (−4.2 percentage points [CI, −6.9 to −1.6 percentage points]) and any obstetrician-gynecologist visits (−3.3 percentage points [CI, −5.9 to −0.8 percentage points]).Figure. Reports of health care usage and barriers to care among women of reproductive age, by rural and urban residence over time.Figures show the annual trends in the unadjusted weighted means of rates of being uninsured (n = 52 190) as well as having usual source of care (n = 51 336), unmet needs for care (n = 52 102), delayed care (n = 52 094), physician visits (n = 52 190), and obstetrician-gynecologist visits (n = 52 190) for women aged 15 to 44 years. Download figure Download PowerPoint Discussion: In this study, rural women were significantly less likely than urban women to have had any visits with physicians, and specifically with obstetrician-gynecologists. Of interest, rural disparities involving usual care sources, delayed care, and unmet care needs were not observed in this study. Such findings could be interpreted to suggest that rural women have equivalent or better access to care than urban women, or that the lower rural rate of physician visits is driven by a lesser need for health care services rather than the presence of barriers to care. However, this is unlikely given that rural women less often receive necessary reproductive and prenatal health services and experience worse perinatal outcomes overall (1). Moreover, a recent study using MEPS data demonstrated the complexity of measuring rural–urban differences in care access and suggested that measures such as having a usual source of care may insufficiently reflect the presence of access disparities and must be interpreted collectively with multiple access measures (3). The authors of that study also note the potential for differences in health care expectations and values between rural and urban residents, which may affect responses to MEPS survey questions (3). Further investigation is necessary to determine whether rural–urban differences exist related to the quality of care available, whether the findings in this study reflect either health service underuse or overuse or both, or whether the care received by rural women was appropriate. Nonetheless, the findings of this study are consistent with the reports of ACOG and others about rural disparities for specialty women's health service utilization and also provide new insight into the relevant care component attributable to physician visits (1). Study limitations include missing respondent data in MEPS, particularly for respondents' rural/urban status, along with previously described challenges in using MEPS and RUCA scores for the study of rural–urban differences in care access (3).Finding that rural women may less often visit obstetrician-gynecologists might have relevance for maternal mortality. Care by skilled birth attendants is essential for managing the types of high-risk pregnancies and deliveries that can result in higher morbidity and mortality rates for both women and newborns (4). Future studies could examine whether the findings here might relate to the known absence of available hospital-based obstetric services in more than half of U.S. rural counties. This resource deficiency is more prevalent in rural counties encountering physician shortages and where at-risk pregnant women face more widespread social determinants of health, such as racial disparities, poverty, lower educational attainment, restrictive reproductive rights, uninsurance, and restricted Medicaid access (5). Multipronged policies are likely necessary to curb rising national maternal mortality rates and address rural health care access disparities.References1. ACOG committee opinion no. 586: health disparities in rural women. Obstet Gynecol. 2014;123:384-8. [PMID: 24451676] doi:10.1097/01.AOG.0000443278.06393.d6 CrossrefMedlineGoogle Scholar2. Kozhimannil KB, Avery MD, Terrell CA. Recent trends in clinicians providing care to pregnant women in the United States. J Midwifery Womens Health. 2012;57:433-8. [PMID: 22954073] doi:10.1111/j.1542-2011.2012.00171.x CrossrefMedlineGoogle Scholar3. Kirby JB, Yabroff KR. Rural-urban differences in access to primary care: beyond the usual source of care provider. Am J Prev Med. 2020;58:89-96. [PMID: 31862103] doi:10.1016/j.amepre.2019.08.026 CrossrefMedlineGoogle Scholar4. Filippi V, Chou D, Ronsmans C, et al. Levels and causes of maternal mortality and morbidity. In: Black RE, Laxminarayan R, Temmerman M, et al, eds. Reproductive, Maternal, Newborn, and Child Health: Disease Control Priorities. 3rd ed. Vol. 2. The International Bank for Reconstruction and Development/The World Bank; 2016:51-70. Accessed at www.ncbi.nlm.nih.gov/books/NBK361917. Google Scholar5. Hung P, Henning-Smith CE, Casey MM, et al. Access to obstetric services in rural counties still declining, with 9 percent losing services, 2004-14. Health Aff (Millwood). 2017;36:1663-1671. [PMID: 28874496] doi:10.1377/hlthaff.2017.0338 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee (H.L.)Office of Planning, Analysis, and Evaluation, Health Resources and Services Administration Rockville, Maryland (C.L., J.S.)Disclaimer: Due to the use of the restricted variables, all data analyses in this article were done at the Center for Financing, Access and Cost Trends at the Agency for Healthcare Research and Quality Data Center. The views expressed in this publication are solely the opinions of the authors and do not necessarily reflect the official policies of the U.S. Department of Health and Human Services, the Health Resources and Services Administration, or the Agency for Healthcare Research and Quality, nor does mention of the department or agency names imply endorsement by the U.S. government.Financial Support: By an appointment to the Research Participation Program at the Health Resources and Services Administration Office of Planning, Analysis and Evaluation, administered by the Oak Ridge Institute for Science and Education through an interagency agreement between the U.S. Department of Energy and the Health Resources and Services Administration.Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-3250.Reproducible Research Statement: Study protocol and statistical code: Available from Dr. Lee (e-mail, hyunjung.[email protected]com). Data set: Available at the Data Centers (https://meps.ahrq.gov/data_stats/onsite_datacenter.jsp).Corresponding Author: Hyunjung Lee, PhD, Oak Ridge Institute for Science and Education, PO Box 117, Oak Ridge, TN 37831; e-mail, hyunjung.[email protected]com.Current Author Addresses: Dr. Lee: Oak Ridge Institute for Science and Education, PO Box 117, Oak Ridge, TN 37831.Drs. Lin and Snyder: Office of Planning, Analysis, and Evaluation, Health Resources and Services Administration, 5600 Fishers Lane, Rockville, MD 20857.Author Contributions: Conception and design: H. Lee, C.C. Lin, J.E. Snyder.Analysis and interpretation of the data: H. Lee, C.C. Lin, J.E. Snyder.Drafting of the article: H. Lee, C.C. Lin, J.E. Snyder. Critical revision of the article for important intellectual content: H. Lee, C.C. Lin, J.E. Snyder. Final approval of the article: H. Lee, C.C. Lin, J.E. Snyder. Statistical expertise: H. Lee, C.C. Lin, J.E. Snyder. Administrative, technical, or logistic support: H. Lee, C.C. Lin, J.E. Snyder. Collection and assembly of data: H. Lee.This article is part of the Annals supplement “Maternal Health in the United States: Findings From the Health Resources and Services Administration and Partners.” The Health Resources and Services Administration provided funding for publication of this supplement. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byAnalyzing Discussions Around Rural Health on Twitter During the COVID-19 Pandemic: Social Network Analysis of Twitter DataCommunity perspectives on pharmacist-prescribed hormonal contraception in rural CaliforniaRural–Urban Differences in the Utilization of Hospital-Based Care for Women of Reproductive AgeLooking Outward to Look Within: The Health Resources and Services Administration Maternal Mortality Summit, and What It Means for Women EverywhereDoris Chou, MD 1 December 2020Volume 173, Issue 11_SupplementPage: S55-S58KeywordsHealth careHealth care qualityHealth care utilizationHealth services administration and managementHealth services researchHealth surveysMaternal healthMaternal mortalityMedical servicesResearch quality assessment ePublished: 1 December 2020 Issue Published: 1 December 2020 PDF downloadLoading ...