Author ORCID Identifier

https://orcid.org/0000-0002-1363-3638

Semester

Summer

Date of Graduation

2023

Document Type

Dissertation

Degree Type

PhD

College

School of Public Health

Department

Epidemiology

Committee Chair

Christa Lilly

Committee Member

Amna Umer

Committee Member

Toni Rudisill

Committee Member

Brian Hendricks

Abstract

Introduction: PNC is essential in protecting the health of birthing person and infant. Teenage and advanced maternal age (AMA) birthing persons are known risk factors for poor birth outcomes. However, less is known about whether these age groups are associated with inadequate PNC. Births to teenagers continue to be of concern in rural areas however, little is known about the association between inadequate PNC and poor infant outcomes in teenage populations. Previous studies have determined that greater risk of inadequate PNC has been linked to more rural areas compared to more urban areas. WV is the third most rural state with the majority of people living in rural areas. While PNC inadequacy has been examined in other rural settings this type of analysis has not been performed in West Virginia. The goal of this dissertation was to fill the gaps in the literature in a series of three studies: 1) The aim of study 1 was to determine which maternal age group was at increased odds of inadequate PNC, 2) The goal of study 2 was to determine if infants of teenagers who received inadequate PNC were at increased odds of poor infant outcomes (longer infant length of stay (LOS), infant being admitted to the NICU, infant being small for gestational age (SGA),and the infant having a low 5-minute APGAR score) compared to infants of teens who received adequate PNC, and 3) The 3rd study aimed to determine the geographic distribution of inadequate PNC in WV using spatial epidemiology.

Methods: Study 1 analysis used logistic regression analysis using the maternal age group of 25-29 years old as the referenced group. Study 2 analysis included logistic regression analysis to analyze the NICU, SGA, APGAR variables and Kaplan-Meier curves to determine if the probabilities of LOS differed between inadequate and adequate PNC groups and a Weibull model was used to perform a survival analysis to determine the bivariate relationship between PNC groups LOS. Study 3 analysis used 2 separate Bayesian Spatial Hierarchical regression models for private and public (WV Medicaid) health insurance groups.

Results: The results of study 1 examining PNC inadequacy across maternal age groups found the adjusted odds of receiving inadequate PNC was significantly higher in birthing persons aged 19 and younger (aOR: 1.3, CI:(1.14,1.43), p < 0.0001), 35-39 (aOR: 1.1, CI:(1.00,1.21), p = 0.05), 40 and older (aOR: 1.3, CI:(1.06,1.52), p = 0.01) compared to persons 25-29 years old. The results of study 2 analyzing PNC inadequacy in teen and their infant outcomes found significantly increased odds of poor infant outcomes such as infant being admitted to the NICU (aOR: 1.84, CI:(1.41, 2.42), p

Discussion: It was found that both teenage and AMA birthing person age groups were at significantly increased risk of inadequate PNC in WV when compared to 25-29-year-olds. Since it is already known these groups are at increased risk of poor infant and birthing persons outcomes, provision of adequate PNC is more important than ever for the health of the birthing person and the infant. Infant outcomes in teenage births were further explored to determine if receiving inadequate PNC had an effect on infant outcomes. The results showed significant effects on infant LOS, NICU status, and APGAR score. These results not only outline the importance of receiving adequate PNC but the importance of reaching the teenage population and giving extra support to help them receive PNC. The third study really highlights the geographic barriers to PNC that exist in WV. The study showed disparities in PNC in the eastern and southern regions of the state which are more rural and mountainous. The study also concluded that having to drive more than 30 minutes is a significant barrier to PNC. This points to transportation and location of birthing facilities being an issue to address for provision of PNC. The study also finds differences in hot spot locations of inadequate care between private and public insurance groups, this leads us to believe that these groups experience barriers to PNC differently. Results of all three studies show the overwhelming importance of receiving adequate PNC and the need to increase support to at risk groups and to help mitigate barriers to PNC across the state.

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