Does geography matter? comparing maternal stressors to birth outcomes
Background: The US continues to see rising trends in the incidence of maternal morbidity and mortality, which contributes to poor infant birth outcomes of preterm birth and low birth weight. The purpose of this dissertation study was to examine the relationship between the experience of stress and birth outcomes of weight and gestational age based on whether the mother resided in a rural or urban location in the state of Missouri. Methods: A secondary data analysis was conducted using the Missouri Department of Health and Senior Services PRAMS survey between 2007-2019. There were 15,938 respondents -- 11,475 urban and 4,463 rural. Stress measures included responses from 13 items on the PRAMS survey related to the experience of stress within the 12 months before delivery of their infant. A mean stress score for each participant was created, which was an average of the 13 stressors experienced. The 13 stressors were also grouped into four different domains: Community, Family/Relationshipd Health. Participant responses are tied to birth certificate data to obtain outcome variables related to infant birth weight (<2500 grams) and gestational age (<37 weeks) at time of delivery. Univariate and multivariate models were analyzed for the total sample and also for urban and rural participants with and without covariates. Results: Rural childbearing women were younger, less likely to have received prenatal care during the first trimester and more likely to have smoked cigarettes than urban childbearing women. Urban women were more likely to have education beyond high school, and more likely to use alcohol during pregnancy. Similar to other research, Black women were more likely to experience PTB or have a LBW infant than other race/ethnicities. The number of stressors reported by both urban and rural women is similar, with rural women reporting slightly more. The experience of stress is significant for both urban and rural women, even when controlling for covariates. Stress scores significantly predicted low birth weight and preterm birth for urban participants. The four different categories of grouped stress scores were not significant for either urban or rural participants and did not significantly predict low birth weight or preterm birth. Conclusion: Health care providers should screen women for stressors related to the social determinants of health in order to provide opportunities for support and intervention. Policies that ensure access to convenient, appropriate obstetric resources for pregnant women, regardless of location could improve outcomes. Research that seeks to understand differences in health between rural and urban populations should consider additional measures related to urban and rural classification of participants.