Reducing maternal health disparities: the rural context




We applaud the focus on overcoming racial inequities in maternity care in the recent editorial by Gelber et al, bolstered by new empirical findings from Howell et al using data from New York City to demonstrate that disparities in maternal morbidity are not just issues of individual race and risk. Rather, a causal factor is structural racism, which occurs when hospital (and other) policies, practices, and norms perpetuate racial group inequities, including in the quality of maternity care.


Health disparities resulting from structural racism are inexcusable and amenable to change, and we join with Howell et al and Gelber et al in calling for policy and programmatic responses to eliminate such disparities.


Gelber et al generalized the findings of Howell et al from New York City to discuss disparities in maternal health care and health outcomes more broadly. In doing so, they described implications for low-volume facilities. However, the editorial did not distinguish low-volume facilities in rural and urban contexts. We are writing to highlight the importance of this distinction.


From workforce to resources to clinical practice patterns to patient case mix to delivery volume and capacity, maternity care differs in rural and urban areas. Additionally, access to maternity care is declining rapidly in rural areas, where women must travel farther and farther each time a hospital or obstetric unit closes. Gelber et al suggest that closing low-quality hospitals may be one way to have an impact on disparities, albeit with the caveat that doing so may result in delays in care.


Hospital closures and subsequent care delays may have vastly different ramifications in urban compared with rural communities, in which the next closest hospital is increasingly distant with each closure. Hospital closures in rural areas may even exacerbate racial and socioeconomic disparities because low-income and black rural women have lower rates of nonlocal childbirth, even after accounting for clinical conditions.


The rural context of maternity care may influence clinician- and hospital-led efforts to eliminate disparities and overcome structural racism. Research in both urban and rural environments must inform these efforts. Howell et al provide valuable data on the urban context.


More information on the hospital’s contribution to disparities in rural contexts is needed. Attention to the differences between rural and urban communities is crucial in the laudable and necessary call to action to address longstanding, persistent, and racial disparities in maternal health.

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Apr 24, 2017 | Posted by in GYNECOLOGY | Comments Off on Reducing maternal health disparities: the rural context

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