Mediators of Race Effects on Risk
of Potentially Avoidable Maternity
Complications among Medicaidinsured Mothers
Sarah B. Laditka, Ph.D
James N. Laditka, D.A., Ph.D.
Janice C. Probst, Ph.D.
South Carolina
Rural Health Research Center
At the Heart of Public Health Policy
Background and Theory

PAMCs, a population-based health care indicator



Builds on epidemiological work of 1970s identifying
"sentinel" conditions, which signal problems with
medical care access or quality (Rutstein et al. 1976)
Extends health services research of 1980s and 1990s
on Ambulatory Care Sensitive (ACS) conditions or
"preventable hospitalization" (Billings et al. 1993,
1996; Bindman et al. 1995)
Assumptions of both ACSs and PAMCs


Timely access to ambulatory health care can reduce
risks of certain medical complications
Large hospital discharge data sets can be used for
assessment
South Carolina
Rural Health Research Center
PAMC: Definition and Example


PAMCs defined based on preventability through timely access to
primary and prenatal care of reasonable quality, and through
healthy behaviors often promoted by prenatal care.
Most PAMCs defined by a combination of primary and secondary
diagnoses using ICD-9-CM codes; selected by panel of
obstetricians and health services researchers.

Example: a delivery hospitalization with a substance abuse
diagnosis and a complication known to be associated with
substance abuse
 Premature Rupture of Membranes
 Intrauterine Growth Restriction
South Carolina
Rural Health Research Center
Preliminary Research I


Used 1997 Nationwide Inpatient Sample (NIS):
 Generated working PAMC list
 Examined PAMC construct and face validity
Used 1988 National Maternal and Infant Health
Survey (NMIHS):
 Examined associations among Adequacy of
Prenatal Care Utilization index (APNCU),
healthy behaviors, and PAMC risk
PAMC citation: Laditka, S.B., J.N. Laditka, M.P. Mastanduno, M.R. Lauria,
T.C. Foster. "Potentially Avoidable Maternity Complications: An
Indicator of Access to Primary and Prenatal Care during Pregnancy."
Women and Health (41(3) In Press).
South Carolina
Rural Health Research Center
Evidence of Preventability, NMIHS
Rating on Adequacy of Prenatal Care
Utilization Index (APNCU):
“Adequate” compared to “Inadequate”:
Odds Ratio 0.43 (95% CI: 0.23~0.81, p<0.01)
“Intermediate” compared to “Inadequate”:
Odds Ratio 0.53 (95% CI: 0.29~0.97, p<0.05)
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Rural Health Research Center
NIS Multivariate Results, Deliveries
Controls: sociodemographics, comorbidities, health system & area,
hospital characteristics, state effects
Odds Ratio & 95% CI
1.5
1.2
0.9
0.6
0.3
0.0
African Hispanic
American
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Rural Health Research Center
Asian
Compared to Non-Hispanic
Whites, All p < 0.0001
Preliminary Research II

Used 2000 Nationwide Inpatient Sample (NIS):
Examined access to health care during
pregnancy for mothers insured by Medicaid.
 Investigated PAMC risks among rural and
urban hospital deliveries for groups of
mothers defined by race or ethnicity,
calculating PAMC rates, logistic regression.

PAMC citation: Laditka, S.B., J.N. Laditka, K.J. Bennett, J.C. Probst
(2005). "Delivery Complications Associated with Prenatal Care
Access for Medicaid-Insured Mothers in Rural and Urban
Hospitals." Journal of Rural Health 21(2), 158-166.
South Carolina
Rural Health Research Center
NIS Rural Urban Results



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In rural hospitals, African Americans had higher
PAMC risk than whites (OR 1.72, CI 1.26-2.36).
In urban hospitals, PAMC risk was not significantly
higher for African Americans.
In urban hospitals, odds of a PAMC for Hispanics
and Asians were about half of those of whites.
Suggested, policymakers should work to reduce
PAMC risks for African American women in rural
areas insured by Medicaid.
South Carolina
Rural Health Research Center
Present Study: Research Objectives




Examine risks of potentially preventable pregnancy
complications
Investigate individual-level factors associated with
these risks.
Describe differences by race/ethnicity, using statelevel data from South Carolina, and the Potentially
Avoidable Maternity Complication (PAMC) indicator.
PAMC indicator identifies pregnancy outcomes
associated with access to prenatal care of
reasonable quality.
South Carolina
Rural Health Research Center
Present Study: Data & Methods



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Hospital discharge data for SC for 2000, linked to
participant demographic and provider data from
South Carolina Medicaid files.
Year 2000 Area Resource File.
26,866 delivery hospital discharges for Medicaid
insured women in South Carolina, 2000.
Calculated PAMC rates, compared prevalence of
unadjusted risk factors among black, Hispanic, and
white mothers; reference group was whites.

Multilevel logistic analyses.

Analyses for ages 10-17 and 18+.
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Rural Health Research Center
Ages 18+, Percent Distribution
Black
Non-H
White
Hispanic
*
3.43
10.37
***
2.35
77.14 ***
41.48
***
51.48
85.37
***
65.34
***
76.11
Disabled
2.54
***
0.00
Diabetes
1.14
***
0.43
Hypertension
1.47
***
0.14
*
0.96
Obesity
1.67
*
0.43
*
1.33
Had a PAMC at delivery
3.92
+
1.85
Education, < 8 years
2.89 *
Marital status, single
Income below poverty
Rural Resident
South Carolina
16.96 ***
15.48
+p<.1, *p<.05, **p<.01, ***p<.001
Rural Health Research Center
**
1.42
0.58
14.48
Multilevel, Selected Results, Ages11-17
Adjusted for Individual, Area, and Hospital Factors
Odds
Ratio
Parameter
LB
UB
***
Black
2.26
1.41
3.62
Hispanic
3.29
1.06
10.25
*
Rural Resident
4.02
1.34
12.02
*
+p<.1,
South Carolina
*p<.05, **p<.01, ***p<.001
Rural Health Research Center
Multilevel, Selected Results, 18+
Adjusted for Individual, Area, and Hospital Factors
Parameter
Black
Hispanic
Marital status, single
Diabetes
Rural resident
+p<.1,
South Carolina
Odds
Ratio
LB
UB
1.01
0.51
1.54
2.4
1.83
0.86
0.29
1.24
1.51
1.19
1.19
0.91
1.92
3.82
2.83
*p<.05, **p<.01, ***p<.001
Rural Health Research Center
*
***
***
**
Results, Black Women

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For ages 10-17, PAMC risks were greater for blacks than whites in
unadjusted and adjusted results.
For ages 18+, adjusted risks for blacks did not differ from whites.
Black mothers 18+ had higher risks than whites: single or
disabled, in poverty or rural county, diabetes or hypertension.
Adjusted results for blacks should be interpreted with caution: do
not suggest blacks are no more likely to have PAMCs than whites.
Suggest PAMC risks for blacks and whites are indistinguishable
when other measured risk factors are controlled.
Black women in South Carolina, as a group, are more likely to
experience PAMCs than whites, because they are much more
likely to have many notable risk factors.
South Carolina
Rural Health Research Center
Results, Hispanic Women

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For young mothers, PAMC rates did not differ significantly
between Hispanics and whites in unadjusted analyses,
which may be attributable small number of Hispanics (n=62),
as the occurrence of PAMC diagnoses was a relatively high
6.5%.
In adjusted analysis, Hispanics 10-17 had higher odds for a
PAMC.
For those 18+, unadjusted PAMC rates were lower for
Hispanics.
Hispanics had lower PAMC risks in multivariate analysis.
Several individual-level risk factors were less prevalent in
Hispanics than whites, e.g., being single, having asthma,
hypertension, diabetes and obesity.
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Rural Health Research Center
Results, All Women


Mothers in rural areas had significant higher
risks of having a PAMC, both in the bivariate
and adjusted results.
Among those age 18+, diabetes emerged as
substantial and significant PAMC risk in
adjusted analyses; highlights importance of
managing diabetes during pregnancy.
South Carolina
Rural Health Research Center
Limitations


Among Hispanics, sample size of young
mothers small.
Cannot identify how long each mother was
enrolled in Medicaid prior to pregnancy.
 Conducted
an analysis of sensitivity to
number of months of pregnancy covered by
Medicaid; results did not differ meaningfully.

Cross-sectional analysis.
South Carolina
Rural Health Research Center
Policy and Practice Implications I



Practitioners should focus prenatal care efforts on
minorities among younger pregnant women.
Practitioners should stress treatment of diabetes for
women of all races
Rural residence is a major risk factor for PAMCs:
highlights South Carolina’s and nation’s continuing
difficulty with ensuring an adequate supply of health
care practitioners in rural areas.

Policy strategies: increase support of rural residency
training; develop designation for practitioners similar to
the Critical Access Hospital program to promote retention
of practitioners in rural areas.
South Carolina
Rural Health Research Center
Policy and Practice Implications II

Policymakers and practitioners should target known risk
h underlying greater PAMC risks for minority women.



Medicaid providers should focus on reducing
avoidable morbidity among blacks, rural residents,
and young Hispanics.
Healthy Start programs, community health centers,
and rural health clinics may be useful for addressing
pregnancy risks associated with poverty, single
marital status, and chronic disease.
In rural areas, poor, disabled, and single pregnant
women may benefit from transportation and other
forms of proactive support to attend prenatal care.
South Carolina
Rural Health Research Center
Mediators of Race Effects on Risk of Potentially
Avoidable Maternity Complications among
Medicaid-insured Mothers
~ Thank You ~
Sarah B. Laditka, Ph.D
James N. Laditka, D.A., Ph.D.
Janice C. Probst, Ph.D.
Study supported by Grant 6 UIC RH 00045-04, U.S. Office of Rural
Health Policy, Health Resources Services Administration
South Carolina
Rural Health Research Center