(339) Association Between Obstetric Care Provider Density and Maternal and Perinatal Outcomes: A Cross-Sectional Analysis

Objective: To examine the association between obstetric care provider density and maternal and perinatal outcomes at the county level.

Study Design: This was a cross-sectional analysis of publicly available Health Resources & Services Administration and limited-use county-level birth certificate data. The primary exposure was the number of obstetric care providers (obstetrician/gynecologist or midwives) per 10,000 births in the county, categorized according to the March of Dimes as full coverage (60 or more providers), moderate coverage (1-59 providers), and desert areas (no providers). Our primary outcome was maternal mortality during pregnancy and up to 42 days postpartum (deaths per 100,000 live births). Our secondary outcomes were maternal mortality up to 365 days post-delivery (deaths per 100,000 live births), stillbirth, preterm birth (PTB), and cesarean delivery (CD) rates. We calculated relative risks (RR) with 95% confidence intervals (95%CI) using Bayesian conditional autoregressive models with Poisson distribution, accounting for spatial autocorrelation and potential confounders.

Results: Of 14,802,676 births included in this analysis, 137,023 (0.9%) births were in desert counties, 1,131,211 (7.6%) births were in counties with moderate coverage and 13,534,442 (91.4%) births were in counties with full coverage (Figure 1). Compared with desert counties, moderate coverage counties had significantly lower maternal mortality up to 42 days postpartum and mortality up to 365 days post-delivery along with higher stillbirth, PTB, and CD rates. Compared with desert counties, full-coverage counties had significantly lower maternal mortality up to 42 days postpartum and mortality up to 365 days postpartum; along with higher stillbirth, PTB, and CD rates (Table 1).

Conclusion:
Increased maternal mortality at the county level is associated with decreased obstetrical provider coverage, with counties that have no providers having the highest mortality rates despite having lower stillbirth, preterm birth, and cesarean rates.