Author Date

2022-03-31

Degree Name

Department

Physiology and Developmental Biology

College

Life Sciences

Defense Date

2022-03-11

Publication Date

2022-03-31

First Faculty Advisor

Dr. Len Novilla

First Faculty Reader

Dr. Jonathon Hill

Second Faculty Reader

Dr. Dennis Eggett

Honors Coordinator

Dr. Roy Silcox

Keywords

maternal morbidity, severe maternal morbidity, maternal mortality, maternal health, Southern Arizona

Abstract

Introduction

Maternal morbidities and maternal deaths are rising at an alarming rate throughout the United States, despite advances in medicine and technology (Centers for Disease Control and Prevention [CDC], 2020). In 2020, maternal deaths climbed to its highest peak in thirty years, at 23.8 deaths per 100,000 births (CDC 2020; CDC 2022b). Maternal morbidities have also increased by nearly 200% from 1993 to 2014 (CDC, 2021). The startling rise in both maternal morbidities and maternal deaths is likely exacerbated by limited access to healthcare and the pervasiveness of chronic diseases such as obesity, diabetes, and heart disease (Carroll, 2017; Geller et al., 2004; World Health Organization [WHO], 2019). Additional reasons for the increase in maternal deaths and maternal morbidities may also involve the increasing age of mothers and more accurate records of maternal death (Carroll, 2017; Joseph et al., 2021; National Vital Statistics Report [NVSR], 2015).

A maternal death refers to “the death of a woman as a result of pregnancy or its management during pregnancy or up to one year following pregnancy” (CDC, 2019). Severe maternal morbidity (SMM) broadly refers to “unintended outcomes of labor and delivery that result in significant short-term or long-term consequences to a mother’s health” (Kilpatrick & Ecker, 2016). While the American College of Obstetricians and Gynecologists (ACOG), as well as the Society for Maternal-Fetal Medicine (SMFM), have not currently endorsed a single definition of severe maternal morbidity, there are various definitions and proposed lists for what conditions constitute SMM. For example, the WHO classifies morbidities as “unanticipated complications of [pregnancy] management” (Pattinson et al., 2009). Researchers representing ACOG have also found that blood transfusion is the most common indicator of SMM and have proposed a list of conditions that can be implemented to further define SMM (Callaghan et al., 2012). The CDC identifies SMM using a list of many indicators such as acute myocardial infarction, eclampsia, and sepsis (CDC, 2020).

While maternal health is frequently addressed at the national and state level, it is equally important to consider maternal health at the community level. Poor maternal health may be more heavily concentrated in particular communities than others and these differences may not be readily observed when only examined at a state or national level.

There is ample research that populations in rural regions generally experience poverty, less access to care, have decreased access to safe and affordable transportation, and frequently experience worse health outcomes. (Castañeda et al., 2015; Castañeda, 2017; Kozhimannil et al., 2019; Rural Health Information Hub [RHIH], 2020).

This study takes into account the challenges of rural populations while analyzing maternal morbidities in the Southern Arizona counties of Maricopa, Pima, Yuma, Santa Cruz, and Cochise. The U.S. Census classifies urban areas as regions of 50,000 or more people (U.S. Census Bureau, 2019) and further states that the term rural “encompasses all population, housing, and territory not included within an urban area” (U.S. Census Bureau, 2019). Based on this definition, only Santa Cruz county is considered rural (U.S. Census Bureau, 2021). However, the counties outside of Arizona’s most densely populated counties of Maricopa and Pima are sometimes referred to as rural since they are regions considered “remote from the state’s major population centers” (Berman, 2019). Due to large differences in population density referenced in Figure 3, the counties of Pima and Maricopa are considered urban and the counties of Yuma, Santa Cruz, and Cochise are generally considered rural.

This research specifically sought to answer whether there are associations between maternal morbidities and elements such as the mother’s geographical residence, race, marital status, age, access to care, and income level throughout Southern Arizona.

The maternal morbidities identified for this study are (1) hemorrhage; (2) infection; (3) eclampsia; (4) hypertension; and (5) drug use. Addressing maternal morbidities early and identifying potential risk factors is an important way to prevent maternal deaths from occurring.

Methods

This study is a descriptive analysis examining the diagnoses of maternal morbidity using 2018 discharge data from the Arizona State Inpatient Databases (SID) developed as part of the Healthcare Cost and Utilization Project (Healthcare Cost and Utilization Project [HCUP], 2018). The percentage of each data element of interest (geographic residence, race, marital status, age, access to care, and median income) in each county was analyzed. A data element was analyzed by the percentage of a normal birth or a morbidity using a chi-squared test for independence. Data elements were then compared within an individual county and also compared to other counties in order to observe relevant trends.

Results

Yuma demonstrated the lowest percentage of normal births and the highest percentages of hemorrhage, eclampsia, and hypertension. Pima county demonstrated the highest percentages of infection and drug use, and the second-lowest percentage of normal births. Overall, the lowest percentage of normal births occurred in Black and Native American populations. Married mothers had the highest percentage of normal births, followed by single mothers and then divorced mothers. The percentage of normal births decreased with age and hypertension increased with age. No uniform trends were observed by payment method and were instead unique to each county. The percentage of normal births increased as median income increased.

Conclusion

This study indicates there is a great need to target maternal health in Yuma and Pima counties. Clinicians and healthcare providers should be aware of the ethnic disparities in maternal health among Black and Native American mothers in Southern Arizona. Effective strategies to improve surveillance and access to care include identifying and addressing maternal morbidities early in pregnancy, during delivery, and during the postpartum period. Longitudinal studies on severe maternal morbidities will help verify or confound trends discussed in this descriptive analysis.