Disparities in Hypertensive Disorders of Pregnancy Across the Levels and Dimensions of Rurality

Open Access
- Author:
- Shoff, Carla
- Graduate Program:
- Rural Sociology
- Degree:
- Doctor of Philosophy
- Document Type:
- Dissertation
- Date of Defense:
- May 29, 2012
- Committee Members:
- Diane K Mc Laughlin, Dissertation Advisor/Co-Advisor
Leif Jensen, Committee Member
Mark R Leach, Committee Member
Stephen Matthews, Committee Member
Marianne Messersmith Hillemeier, Committee Member - Keywords:
- pregnancy
rural
health disparities
multilevel modeling
health care - Abstract:
- Hypertensive disorders of pregnancy (e.g., gestational hypertension, preeclampsia, and eclampsia) are among the leading causes of maternal morbidity in the United States (Waterstone, Bewley, Wolfe, and Murphy 2001). Hypertensive disorders of pregnancy (HDP) have detrimental effects on both the mother and her infant (Bryson, Ioannou, Rulyak, and Critchlow 2003). Approximately 5 to 10 percent of pregnant women in the United States experience HDP (Bryson, Ioannou, Rulyak, and Critchlow 2003; Sibai, Ewell, Levine, Klebanoff, Esterlitz, Catalano, Goldenberg, and Joffe 1997). Differentials in HDP have been well documented for women of various racial and ethnic groups, women of different socioeconomic statuses, and for those women participating in individual health risk behaviors. Despite the growing body of research on disparities in HDP, and the fact that 20 percent of births that occur in the United States are to women who live in rural areas (Lishner, Larson, Rosenblatt, and Clark 1999), very little attention has been paid to disparities in HDP in rural areas compared to more urbanized places. To date, research has not addressed geographical differentials in HDP due to individual and residential characteristics. This dissertation seeks to examine the extent to which the odds of a woman experiencing HDP differ by individual and residential/county-level characteristics. Predictors of HDP may not be limited to individual-level maternal demographic and behavioral characteristics. The characteristics of counties in which women live also may affect the odds of a woman experiencing HDP. In addition, the effect of individual characteristics may vary from place to place and the impact of residential context may vary from person to person; therefore, it was necessary to test for cross-level interactions in order to tease out the relevant effects on health (Verheij 1996). In order to correctly account for the hierarchical nature of the hypothesized relationships and structure of the data, multilevel logistic regression models were estimated using data from the 2007 National Center for Health Statistics Non-Public-Use Natality Detail Files linked to characteristics of the women’s county of residence across rural and urban areas of the United States. This study goes beyond prior research on HDP by demonstrating how the combined attributes of the places in which women live (such as population density, isolation, and large distances between residences and health care services) affect the likelihood of a pregnant woman experiencing HDP. In addition, this dissertation builds upon previous research that has focused on rural/urban health disparities and disparities in pregnancy outcomes by considering how multiple indicators of rurality (i.e., ecological, occupational, and sociocultural dimensions) are associated with HDP. Specifically, the results of this study identified that when women live in more rural areas they are more likely to experience HDP. After establishing this geographical disparity in HDP, further analyses revealed that the effect of individual maternal characteristics on HDP varied significantly by the level and dimension of rurality of the woman’s residential county. By identifying these differences, more appropriate strategies for reducing the odds of HDP can be established through health policy and other initiatives.