Health Assessment of a Rural Obstetrical Population in a Midwestern State

Lisette T Jacobson^*, Jennifer Duong, David Grainger, Tracie Collins, Darren Farley, Michael Wolfe, Frank Dong and Benjamin Anderson

University of Kansas School of Medicine Wichita, Wichita, Kansas, United states

Corresponding Author:

Lisette T Jacobson
University of Kansas School of Medicine Wichita
Wichita, Kansas, United States
Tel: (316)293-3484
E-mail: ljacobson@kumc.edu

Received April 26, 2016; Accepted April 28, 2016; Published April 30, 2016

Citation: Jacobson LT, Duong J, Grainger D, Collins T, Farley D, et al. (2016) Health Assessment of a Rural Obstetrical Population in a Midwestern State. J Preg Child Health 3:252. doi:10.4172/2376-127X.1000252

Copyright: © 2016 Jacobson LT, et al., This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

A critical access hospital in a Midwestern state experiences an alarming number of high-risk pregnancies including pregnancies complicated by gestational diabetes mellitus. A health collaborative among local healthcare providers, a regional health system, a medical school, and the state health department was established to improve pregnancy and birth outcomes. The purpose of this study was to learn about the characteristics and health behaviours of rural pregnant women. A survey was administered to women who received care at two critical access hospitals and one federally qualified health centre between January and March 2015. Survey questions focused on pregnancy risk factors and ascertained health status, anthropometrics, prenatal education, dietary habits, physical activity, health behaviours, family medical history, and demographic characteristics. Descriptive analyses were conducted. Sample size included 177 rural women. Most respondents were Hispanic (50.3%), 18-25 years old (48.6%), completed some high school (20.5%) or high school graduate (30.7%), WIC enrolled (51.7%), and an income of < $25,000/year (54.2%). The majority were overweight (34.4%) or obese (41.6%) during pregnancy and 54% engaged in 30 minutes of moderate physical activity per day for ≤ 2 days per week. Education regarding fetal movement counts was minimal. Nearly one-third (30.5%) had an immediate family member with diabetes and 24.3% had an immediate family member with heart or circulation problems. Findings indicate that this rural population is at risk for pregnancy complications including gestational diabetes leading to an increased risk for developing type 2 diabetes and cardiovascular disease later in life. This study is an initial step toward understanding rural pregnant women in the catchment area. Follow-up studies that could further guide the design for intervention programming that aims to reduce the risk for cardiovascular disease are needed. Additional studies into annual screening for pregestational diabetes and early serial screening for gestational diabetes are also warranted.

Keywords

Pregnancy; Maternal health; Rural health; Obstetrics; Gestational diabetes; Risk factors; Health behaviours

Introduction

A critical access hospital providing a full spectrum of healthcare services to 12 rural counties located in the southwest corner of a Midwestern state experiences a high number of complicated births. Women with pregnancies complicated by gestational diabetes mellitus (11%) and gestational hypertension (7%) deliver at this hospital [1].

Gestational diabetes mellitus (GDM) is a form of diabetes that occurs during pregnancy [2]. GDM should be addressed as a public health concern because of its association with adverse health outcomes for mother and infant. Women with gestational diabetes are more likely to experience pregnancy complications including caesarean section, gestational hypertension, and preeclampsia [3-6]. More importantly, women with GDM have a 7-fold increased risk of developing type 2 diabetes in the future compared to women who did not have GDM [7]. Infants born to mothers with GDM are more likely to experience birth injuries, neonatal hypoglycaemia, neonatal cardiac dysfunction, macrosomia, shoulder dystocia, and stillbirth [8-11]. Additional research findings suggest that infants born to women with GDM are at greater risk for developing metabolic syndromes [12], diabetes [13], and obesity [14-16].

Limited access and availability of healthcare services in rural areas is well documented [17-21] and rural pregnant women in particular have reduced access to physicians specializing in obstetrics [22,23].

Evidence suggests disparities in the delivery of healthcare services to rural pregnant women [23] including longer drive times to hospitals for prenatal care [24], late entry into prenatal care [25], and an increased likelihood of unhealthy pre-pregnancy weight [26]. Additionally, rural pregnant women experience adverse birth outcomes including an increased likelihood of low birth weight babies and preterm delivery [23,27-29]. Therefore, the American College of Obstetricians and Gynaecologists (ACOG) encourages collaboration among state and local maternal-child and rural health agencies to identify the health needs of rural, reproductive age women and perceived barriers to access and delivery of healthcare services [30].

Given that rural reproductive age women experience disparities in healthcare services[23-26] poor birth outcomes [27-30], high smoking rates [31,32] and reduced breastfeeding rates [31] the need for a collaborative approach among healthcare providers to offer obstetrical services becomes critical. Against this background, a health collaborative among local healthcare providers, a regional health system, a medical school, and the state health department was established with the overarching goal of improving pregnancy and birth outcomes among reproductive age women in an underserved frontier rural location.

The purpose of the current study was to learn about the characteristics and health behaviours of pregnant women in this area. Due to the high rate of pregnancy complications, the study focused on pregnancy risk factors including weight, exercise, diet, health behaviours, prenatal education, family medical history, and demographic characteristics.

Methods

Study Participants

This study was a cross-sectional study and participants were recruited by two critical access hospitals and one federally qualified health center. These healthcare providers offer obstetrical services to pregnant women who reside in 12 counties. Inclusion criteria for study participation included: receiving obstetrical care at any one of the study locations, able to read and understand English or Spanish, 18- years-old or older, and able to give informed consent.

Study Procedures

The research team provided a three-hour on-site training session to hospital/center representatives at a community partners meeting at one of the three study sites. Representatives were instructed on procedures, participant eligibility requirements, tips to keep track of participants, mechanisms to collect and return original survey documents to the research team, and guidance on issuing incentives.

Hospital/center representatives provided all obstetrical patients with a survey during one of their prenatal appointments. Participation was completely voluntary. Prior to participating in the study, participants had the option of calling the research team with any questions. Surveys were self-administered. Upon completion of the survey, each participant was given a $10 gift card.

Completed paper surveys were mailed to the principal investigator via regular US mail on a bi-weekly basis. Hospital/center representatives maintained a list of eligible participants and monitored which subjects were offered participation to avoid duplication of survey completion. To maintain confidentiality and privacy of study participants, identifying patient information was not collected. Data were collected between January and March 2015. In accord with prevailing legal and ethical principles, the Institutional Review Board at the University of Kansas School of Medicine-Wichita approved this study.

Survey Instrument

Participating healthcare providers indicated that they served a large Hispanic population, and thus the survey instrument was available in English and Spanish. Translation services were provided by a professional translator familiar with this region of the state. Eligible participants were asked questions regarding their health status and prenatal education, diet, weight and exercise, smoking status and vitamin use, use of technology, family medical history, and demographic characteristics. Before the survey was piloted, feedback from four co-investigators was requested and incorporated. The survey was piloted among five individuals and their suggestions were also incorporated into the final survey instrument.

Study Variables

The survey instrument contained selected survey items from national datasets and guidelines; additional survey items were created as well. Health status and prenatal education consisted of six survey items including two items from the American College of Obstetricians and Gynaecologists Guidelines for Perinatal Care [33]. Diet consisted of five survey items including one item from the National Health and Nutrition Examination Survey 2013-2014 [34] and two items from the Dietary Guidelines for Americans [35]. Weight and exercise consisted of six survey items. Smoking and vitamin use also consisted of six survey items. Two of the items were used from the Pregnancy Nutrition Surveillance System questionnaire [36,37]. Use of technology comprised four survey items. Family medical history consisted of three survey items. All family medical history survey items were used from the Women’s Health Initiative dataset and they were based on dichotomous responses (yes vs. no) [38]. The first question asked whether any of the participant’s immediate family members had ever been diagnosed with or treated for diabetes. The second question asked whether any of the participant’s immediate family members had ever been diagnosed or treated because of heart problems, blocked or narrowed blood vessels, stroke or other problems with their blood circulation. For both questions, immediate family member was defined as a mother, father, brother, or sister directly related to the participant. If participants responded “yes” to the second question, then they were asked to identify the heart or circulation problem that their immediate family member was diagnosed with or treated for. Last, six survey items regarding demographic characteristics were included. All variables were included in this study’s descriptive analysis.

Statistical Analysis

Descriptive analyses were conducted to examine maternal demographics, health status, diet, exercise, health behaviours, use of technology, and family medical history. Summary characteristics for all variables were presented as frequencies and percentages. Data were analysed at the group level using the SAS System Version 9.3.1 [SAS Institute Inc., Cary, NC, USA).

Results

A total of 185 surveys were distributed to women who were eligible to participate in the study; 177 women completed the survey. The response rate was 95.7%. Half of survey responders were Hispanic (50.3%) and nearly half were age 18 to 25 years (48.6%), (Table 1).

Table 1: Participant Demographics and Use of Technology (†: One participant did not provide a type of insurance; ¶: Participants were not required to indicate language preference).

Additional characteristics of respondents included some high school (20.5%) or high school graduate (30.7%), WIC enrolment (51.7%), and an average annual income of < $25,000 (54.2%). More than one fifth (23.7%) of participants indicated that they were uninsured.

A majority of women reported owning a cell phone (95.5%) and use of text messaging (92.1%). When using text messaging, 80.7% of women chose English as their preferred language and 19.3% preferred Spanish. When asked about participating in a health promotion program, most participants said they would regularly use the Internet (70.3%) and text messaging (74%).

Maternal Health Status, Prenatal Education, and Health Behaviours

A majority of participants (46.2%) reported being in their third trimester of pregnancy (Table 2).

Table 2: Maternal Health Status, Prenatal Education, and Health Behaviors (†: Multiple medical conditions could have been selected; ¶: Education percentage calculated out of N=177. Mode of prenatal education percentage calculated out of number responding to this question, which may not equal 100%).

During weeks 4-36 of pregnancy, 88.1% of women reported regularly visiting a physician (approximately 1-2 times every month). After week 37 of pregnancy, 69.4% of women reported regularly visiting a physician every week. A majority of women reported not being diagnosed or treated for a medical condition during their current pregnancy (83.6%) or prior to their current pregnancy (84.4%).

Additionally, a majority of women reported receiving prenatal education regarding nutrition (67.2%), exercise (61.6%), weight management (59.3%), and breastfeeding (51.4%). Women reported receiving prenatal education mainly via pamphlets or brochures; however, information on weight and exercise was largely provided via provider counselling, 41.9% and 38.5% respectively. Information on fetal movement and kick counts was mainly provided via brochures (38.6%) and less via the provider (31.4%). Participants reported receiving prenatal education primarily during the third trimester followed by the second and first trimester.

Furthermore, 86.4% of women reported not smoking cigarettes three months prior to pregnancy. More than half of participants (58%) reported not taking multi-vitamins prior to pregnancy though the majority (73.5%) reported taking multi-vitamins once they were pregnant. Likewise, 68.9% reported not taking prenatal vitamins with folic acid prior to pregnancy, but 85.2% reported taking prenatal vitamins with folic acid during pregnancy.

Diet, Weight and Exercise

A majority of women (63.6%) rated their overall dietary health as good (Table 3). Women frequently visited the grocery store to buy food for their households, with the majority making one to four visits a week (63.3%). More than half of participants reported traveling five miles or less (61.7%) to get to the nearest grocery story whereas 16% reported traveling 26 miles or more. Most women agreed that they consumed a variety of protein foods (61.6%) as well as a variety of vegetables (54.2%). Three months prior to pregnancy, 59.7% of women perceived their body mass index (BMI) within the category of normal. However, with use of reported height and weight, calculations of BMI revealed that only 41.5% met criteria for the category of normal prior to pregnancy. Also, prior to pregnancy, 28.1% and 26.2% of women were overweight or obese based on computed BMI. During pregnancy upon survey completion, computed BMI indicated that 34.4% and 41.6% were overweight or obese respectively.

Table 3: Diet, weight and exercise (†: Per cent calculated out of participants responding with weight and height information to determine body mass index; ¶: Body mass index categorized based on the following: underweight (less than 18.5), normal (18.5 to 24.9), overweight (25.0 to 29.9), obese (30.0 and greater); §: Body mass index computed using [weight (in pounds)/height2 (in inches)]).

Additionally, a majority of participants reported engaging in no moderate physical activity (31.2%) or less than 30 minutes of moderate physical activity (41.4%). Only 23.9% of women reported engaging in moderate exercise for 30 minutes or more two days a week during their pregnancy. Most women agreed (57.6%) or strongly agreed (20.3%) with the statement, “I have access to facilities in my community to maintain a physically active lifestyle.”

Family Health History

Last, 30.5% of women reported having an immediate family member who was diagnosed with or treated for diabetes mellitus (Table 4). Nearly a quarter (24.3%) of women reported having an immediate family member who was diagnosed or treated for cardiovascular problems. Out of 43 participants who reported having an immediate family member with cardiovascular problems, 37.2% reported a family member who experienced a heart attack, 27.9% had heart or circulation problems, and 25.6% had chest pain from a heart problem.

Table 4: Family Health History (†: Family member: mother, father, brother, or sister; ¶: Cardiovascular problems: heart problems, blocked or narrowed blood vessels, stroke or other problems with blood circulation; §: Percentage calculated out of 43 participants reporting having a family member diagnosed or treated for cardiovascular problems).

Discussion

This study’s findings report the prevalence of risk factors associated with pregnancy complications and potentially adverse health outcomes increasing maternal, fetal, and neonatal morbidity and mortality. Findings support that this population is at risk.

Potential unawareness of this risk could lead to a delay of entry into prenatal care and subsequent delay of diagnosis of gestational diabetes or other serious pregnancy conditions [21-23]. Overall results support current literature suggesting that rural reproductive age women experience poor health outcomes and have less access to healthcare services compared to urban women [20-22, 26-28].

Most pregnant women in this health assessment were Hispanic, in their early reproductive years, and of low socio-economic status (measured by level of income and education). Nearly a quarter did not have health insurance coverage, which is consistent with the overall national, rural uninsured rate at 22.3% [39] and the national uninsured rate for the most remote rural areas at 23% [40]. Lack of healthcare coverage may have contributed to late entry into prenatal care thereby increasing the odds of potential adverse birth outcomes. Our findings indicate a need to enrol women in health insurance prior to pregnancy and to make them aware of other public assistance programs for which they may be eligible.

Many women shared in the education of weight, exercise, and diet, all of which are modifiable risk factors and have been used in randomized control trials to prevent gestational diabetes. Unfortunately, research findings remain inconclusive on the effects of combined or stand-alone diet and exercise interventions during pregnancy for preventing GDM [41-43]. Interventions aimed to reduce GDM among the obstetrical patient population exist [44-50] but there are no interventions that specifically target rural pregnant women. Therefore, results from this health assessment uniquely contribute to existing knowledge about the possible health needs of rural reproductive age women though the data collected is limited other than providing us with a baseline and follow-up studies are warranted.

Scientific evidence suggests that women who develop gestational diabetes are older non-White have greater parity have higher body mass index gain excessive weight during pregnancy, and have a history of gestational diabetes or family history of type 2 diabetes [51-57]. This study’s results indicate several risk factors for developing gestational diabetes including being non-White, having higher body mass index, and having a family history of diabetes. Though, despite identified risk factors for pregnancy complications, the majority of women reported not being diagnosed or treated for a medical condition prior to and during their pregnancy. This could be attributed to a large proportion of women being in their first or early second trimester particularly since screening for gestational diabetes usually occurs between weeks 24-28 of gestation [58].

Furthermore, in populations at risk of developing gestational diabetes and/or with a high rate of gestational diabetes, lower screening cut-offs (using 1 hour screen of 130-135 mg/dL as the cut-off versus 140 mg/dL) in addition to early and serial screening in at-risk women may improve the detection of gestational diabetes and lead to improved outcomes with early diagnosis and opportunity to intervene [33]. To this end, modification of current screening protocols and screening cut-off levels, as noted above, may need to be explored further especially with regard to coverage by patients’ insurance companies.

Patients’ family medical history suggests increased potential for health risks during the remainder of pregnancy and beyond. Nearly one third of women had an immediate family member who was diagnosed or treated for diabetes, a risk factor for developing gestational diabetes [59], and almost a quarter of women reported having a family member diagnosed or treated for cardiovascular problems. Diabetes is a coronary heart disease risk equivalent as it confers a high risk of new coronary heart disease within 10 years [60]. As gestational diabetes is a risk factor for type 2 diabetes, family medical history is critical in assessing a woman’s risk. Our results suggest that rural women of reproductive age may be at high risk for developing diabetes mellitus. Additional studies are needed to further understand the risk factors for diabetes as well as future cardiovascular events among rural women [61].

Prenatal Education

Starting in the first trimester, most healthcare providers counselled women on diet, exercise, weight, and breastfeeding. Pamphlets and brochures continue to be the most popular method of prenatal education. More than half of participants reported receiving breastfeeding education; however, less than 20% reported provider counselling on the subject. Promotion of breastfeeding support resources during the prenatal period is critical to the success of breastfeeding initiatives [31] and thus efforts should be made to counsel rural women early on in their pregnancy. Additionally, in an effort to lower risk of stillbirth, formal fetal movement education should be considered. Compared to formal surveillance protocols with biophysical profile/non-stress testing, fetal movement counts by the patient is shown to be equivalent in reduction of the stillbirth rate [62]. In summary, sharing in the education of fetal movement, diet, exercise, weight, breastfeeding, safe sleep practices, and immunizations may be more effective if initiated during the first trimester with periodic updates throughout pregnancy rather than toward the end of pregnancy as most women reported.

Diet, Weight and Exercise

Rural women reported an overall healthy diet and regularly visited grocery stores to buy food for their households. However, it is difficult to assess whether women were actually eating a balanced diet as selfreported dietary habits may not always translate to a healthy diet. Dietary habits of women at risk for developing gestational diabetes and other pregnancy complications requires additional research though evidence suggests that interventions with a component focusing on dietary advice can reduce maternal weight gain[43,45,46,63,64]. Therefore, we recommend that additional efforts be made to understand dietary choices of this rural population prior to implementing dietary counseling as a component of a health promotion intervention [65].

Managing maternal weight gain during pregnancy is a modifiable behavior that is imperative to reducing the likelihood of developing gestational diabetes and other pregnancy complications [55]. Appropriate maternal weight gain during pregnancy is related to body mass index (BMI) at the initial prenatal visit [66]. Even though the survey asked participants for weight and height three months prior to pregnancy, ideally, BMI category should be similar to the BMI category calculated at the initial prenatal visit. In this study, we found that many women underestimated their BMI as normal weight when in actuality participants were overweight. Likewise, women who perceived their BMI as overweight were actually obese.

This could be attributed to the fact that BMI category was not clearly described on the survey instrument and, thus, this is an area that should be investigated further in follow-up studies. Nonetheless, since women in rural areas have increased odds of being overweight or obese compared to urban women [26], healthcare providers for rural populations should continue to emphasize weight gain recommendations throughout pregnancy.

Engaging in physical activity prior to and during pregnancy may lower the risk of developing gestational diabetes mellitus and other pregnancy-related conditions [67,68]. The American College of Obstetricians and Gynaecologists (ACOG) suggests that women can safely participate in a wide range of exercise during pregnancy. Specifically, ACOG recommends 30 minutes or more of moderate exercise a day on most, if not all, days of the week for pregnant women [68]. The majority of women in our study engaged in moderate exercise for 30 minutes or less per day for the duration of less than three days a week. Even though women reported not engaging in adequate exercise, they indicated having access to facilities in their communities to maintain a physically active lifestyle. Follow-up research should focus on what prevents women from going to these facilities.

Limitations and Future Direction

This study’s findings are somewhat limited due to use of its crosssectional design for obtaining meaningful data to guide health service planning. Women completed the survey at different time points during pregnancy, which limited our ability to analyse our findings particularly as they relate to the diagnosis of gestational diabetes. Additionally, results may not apply to other rural areas in the United States due to the socio-demographic uniqueness of the obstetrical population. Other limitations include participants’ self-report bias and quantitative nature of the survey, which may not provide specific enough information to design a health promotion intervention to improve pregnancy outcomes.

Moving forward, a collaborative partnership between rural healthcare provider systems and public health agencies is paramount to improving the health outcomes for women and their families. This partnership becomes particularly important for extreme, frontier rural locations where access and delivery of healthcare services is difficult at best. Further, additional research is needed into women’s perceived value of an intervention that addresses diet, exercise, weight, and support services during and after pregnancy. Future studies should identify at-risk women who may have undiagnosed pre-gestational diabetes so that optimal glycaemic control can be achieved during the pre-conception period thereby reducing the risk of first trimester miscarriage and congenital anomalies.

Conclusions

The major findings of this study indicate that this group of women is at high risk for developing diabetes and coronary heart disease later in life. Moreover, a general unawareness of risk factors for pregnancy complications appears to exist, which could lead to a delay in diagnosis of gestational diabetes or other pregnancy conditions. Women in this rural area appear to be at high risk for developing gestational diabetes and lower screening cut-offs along with early and serial screening may improve the detection of gestational diabetes leading to improved pregnancy and birth outcomes. Further studies regarding review and potential modification of current screening protocols are warranted.

Implications for Public Health

This study’s outcome has several implications for public health practice. First, collaboration among public health departments, critical access hospitals, and federally qualified health centers becomes critical to optimize health outcomes especially in rural locations. Second, public health agencies can play a key role in connecting low-income rural women with health insurance coverage options, public assistance programs (e.g. WIC), prenatal education, and preventive screening, referral and immunization services. Though this study is an initial and important first step toward understanding women in our rural catchment area, it is important to note that follow-up studies are needed particularly those that could further guide the design of interventional trials.

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