# Race and Place: An intersectional approach to maternal health inequities and healthcare systems factors in the Rural South

> **NIH AHRQ R36** · UNIV OF NORTH CAROLINA CHAPEL HILL · 2022 · $42,552

## Abstract

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...

## Key facts

- **NIH application ID:** 10558190
- **Project number:** 1R36HS029134-01
- **Recipient organization:** UNIV OF NORTH CAROLINA CHAPEL HILL
- **Principal Investigator:** Mekhala Vidurangi Dissanayake
- **Activity code:** R36 (R01, R21, SBIR, etc.)
- **Funding institute:** AHRQ
- **Fiscal year:** 2022
- **Award amount:** $42,552
- **Award type:** 1
- **Project period:** 2022-09-30 → 2023-09-29

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10558190

## Citation

> US National Institutes of Health, RePORTER application 10558190, Race and Place: An intersectional approach to maternal health inequities and healthcare systems factors in the Rural South (1R36HS029134-01). Retrieved via AI Analytics 2026-05-26 from https://api.ai-analytics.org/grant/nih/10558190. Licensed CC0.

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