Project Summary/ Abstract: This project is responding to Special Emphasis Notice (SEN) NOT-HS-21-014, Interest in Health Services Research to Advance Health Equity. The burden of maternal morbidity is borne disproportionately by both 1) Black, Hispanic and Indigenous birthing people and 2) people living in rural areas in the United States. Severe maternal morbidity (SMM) is largely preventable, contributes significantly to maternal mortality, and has its own far-reaching health consequences. Recent research on racial and rural disparities in SMM misses an important fact: rural people of different races and ethnicities live in different geographic contexts and may therefore have differential access to healthcare services. The racial composition of rural counties varies widely: Black residents are 1-3% of the rural population in the Midwest and Northeast but 20-40% in the South. Even within the South, areas like Appalachia are >90% White while the Black Belt contains counties that are over 50% Black. Previous research has found worse infrastructure, lower overall health, and earlier mortality among residents of the Black Belt, though maternal outcomes have not been evaluated. A truly intersectional approach to addressing disparities related to rurality and race requires considering the geographic context in which rural people reside. This proposal incorporates intersectionality by including racial composition of county as a contextual factor to describe the distribution of SMM in rural North Carolina (NC). The proposal also aims to go beyond describing health disparities by examining healthcare systems factors that may vary by racial composition of county and contribute to SMM. This study will sample from a rural NC population. The primary data source will be birth certificates linked to Medicaid claims, ideal for identifying SMM, but will also leverage publicly and institutionally available data for comprehensive evaluation. Aim 1 will use quintiles of racial composition of county, operationalized as proportion of Non-Hispanic Whites (NHW) in each county, to describe the distribution of 1) SMM among Non-Hispanic White, Non-Hispanic Black, Hispanic, and Indigenous residents of rural counties and 2) healthcare systems factors. These factors include: presence of an obstetric unit, provider mix, number of hospital beds, hospital type, hospital services, and presence of birthing center. Aim 2 will evaluate the impact of obstetric-unit closures (known to be concentrated in areas where residents are predominantly Black or Indigenous) in counties with high proportions of Non- Hispanic Whites (high NHW) vs. low proportions of Non-Hispanic Whites (low NHW). Finally, Aim 3 will use a decomposition approach to estimate the joint disparity in SMM related to the social status of race and the social context of racial composition of county to determine the extent to which the availability of healthcare systems factors explain this joint disparity. The proposed re...