Perinatal Health Outcomes Across Rural and Nonrural Counties Within a Single Health System Catchment

Abstract

Background: Perinatal health outcomes are influenced by a variety of socioeconomic, behavioral, and economic factors that reduce access to health services. Despite these observations, rural communities continue to face barriers, including a lack of resources and the fragmentation of health services.

Objective: To evaluate patterns in health outcomes, health behaviors, socioeconomic vulnerability, and sociodemographic characteristics across rural and nonrural counties within a single health system catchment area.

Methods: Socioeconomic vulnerability metrics, health care access as determined by licensed provider metrics, and behavioral data were obtained from FlHealthCHARTS.gov and the County Health Rankings. County-level birth and health data were obtained from the Florida Department of Health. The University of Florida Health Perinatal Catchment Area (UFHPCA) was defined as all Florida counties where ≥5% of all infants were delivered at Shands Hospital between June 2011 and April 2017.

Results: The UFHPCA included 3 nonrural and 10 rural counties that represented more than 64,000 deliveries. Nearly 1 in 3 infants resided in a rural county, and 7 out of 13 counties did not have a licensed obstetrician gynecologist. Maternal smoking rates (range 6.8%-24.8%) were above the statewide rate (6.2%). Except for Alachua County, breastfeeding initiation rates (range 54.9%-81.4%) and access to household computing devices (range 72.8%-86.4%) were below the statewide rate (82.9% and 87.9%, respectively). Finally, we found that childhood poverty rates (range 16.3%-36.9%) were above the statewide rate (18.5%). Furthermore, risk ratios suggested negative health outcomes for residents of counties within the UFHPCA for each measure, except for infant mortality and maternal deaths, which lacked sample sizes to adequately test.

Conclusions: The health burden of the UFHPCA is characterized by rural counties with increased maternal death, neonatal death, and preterm birth, as well as adverse health behaviors that included increased smoking during pregnancy and lower levels of breastfeeding relative to nonrural counties. Understanding perinatal health outcomes across a single health system has potential to not only estimate community needs but also facilitate planning of health care initiatives and interventions in rural and low-resource communities.

Keywords: County Health Rankings; FLHealthCHARTS.gov; breastfeeding; catchment area; electronic health records; maternal smoking; north central Florida.

FIG. 1.

Rates of preterm births in Florida and the UFHPCA. Left—statewide map of preterm birth rates (annualized 2011–2017) with UFHPCA (left; outlined in black). The 13 catchment counties are ordered by rate of preterm births. Right—the statewide rate (10.1% from June 2011 to April 2017) is denoted by the vertical black line. Rates are weighted annually by county population. Ten out of 13 UFHPCA counties had preterm birth rates above the statewide rate, indicating higher levels of health burden within the UFHPCA. UFHPCA, University of Florida Health Perinatal Catchment Area.

FIG. 2.

Rates of maternal smoking during pregnancy in Florida and the UFHPCA. Left—statewide map of the percent of births (annualized 2011–2017) to mothers who reported smoking during pregnancy. UFHPCA outlined in black. Right—the 13 catchment counties ordered by maternal smoking rate, the statewide rate (6.2% between June 2011 and April 2017) is denoted by the vertical black line. Rates are weighted annually by county population. All 13 counties in the UFHPCA had maternal smoking rates during pregnancy above the statewide rate.

FIG. 3.

Rates of breastfeeding initiation in Florida and the UFHPCA. Left—statewide map of county-level breastfeeding initiation rates (annualized 2011–2017) with the UFHPCA (left; outlined in black). Right—the 13 catchment counties ordered by breastfeeding initiation rate where the statewide rate (82.9% between June 2011 and April 2017) is denoted by the vertical black line (right). Rates are weighted by county-level annual population. Within the catchment, all counties, except Alachua County, had rates below the statewide rate, indicating higher levels of health burden within the UFHPCA.

FIG. 4.

Poverty rate for families with children under five in Florida and the UFHPCA. Left—statewide map of families with related children under the age of five living below the poverty rate (annualized 2011–2017) with the UFHPCA (left; outlined in black). Right—the 13 catchment counties are ordered by rate where the statewide rate (17.5% from June 2011 to April 2017) is denoted by the vertical black line (right). Rates are weighted by county-level annual population. Within the UFHPCA, all counties had poverty rates above the statewide rate, indicating higher levels of health burden within the UFHPCA.

FIG. 5.

Rates of access to household computing devices in Florida and the UFHPCA in 2017. Left—statewide map of rates of computing device access within households (2017) in the UFHPCA (left; outlined in black). Right—the 13 catchment counties are ordered by household rates of access to one or more computing device, where the 2017 statewide rate (87.9%) is denoted by the vertical black line (right). Within the UFHPCA all counties, except Alachua County, had computing device access rates below the statewide rate, indicating higher levels of health burden within the UFHPCA.

FIG. 6.

Rural versus nonrural risk ratios, 2011–2017. Plot of rate ratios and CIs for comparing the health behaviors, health care providers, and health outcomes between the rural and nonrural counties in the UFHPCA. LCL and UCL given for significance of p ≤ 0.05 and * marks statistically significant disparity. Rates of intent to breastfeed and all three physician types examined were significantly lower in the rural counties than in the nonrural counties, whereas rates of maternal smoking and preterm birth were significantly higher in rural counties than in nonrural counties. CI, confidence interval; LCL, lower confidence interval; UCL, upper confidence interval.