Spatial Analysis of Birth Center Locations and Service Catchment Areas in the Contiguous United States: An Application of Public Health Critical Race Praxis

摘要

Objectives: Birth center care is associated with improved health for childbearing people of all racial or socioeconomic groups. Black people are underrepresented among birth center clientele and the midwifery workforce. This is troublesome given the legacy of Black midwives in the United States (US), who were systematically disenfranchised by the obstetrical field in the late 19th and early 20th centuries. Applying Public Health Critical Race Praxis, the objectives of this dissertation research are to examine the distribution of birth center locations in the contiguous US, describe their service communities, and explore how structural racism (e.g., employment inequity) influences access to birth center care for Black childbearing people.Methods: Leveraging secondary data, this research applied spatial analytic methods to illustrate birth center locations and assess spatial clustering (i.e., global and local Moran's I) of states and counties with birth centers. This dissertation also investigated the association between quantitative measures of structural racism and the presence of birth centers using multivariable logistic regression; and compared childbearing populations within birth center catchment areas to those outside.Results: Global Moran's I testing indicated significant spatial autocorrelation of counties with birth centers, including by attribute (e.g., accreditation). Multivariable regression demonstrated significantly higher odds of birth center presence at the county level with increased racial segregation and increased racial inequity regarding educational attainment, controlling for population size and midwifery scope. Compared to childbearing populations outside, those within birth center catchment areas had significantly larger proportions identifying as Asian, Black, and Hispanic.Conclusions: Gaps in birth center locations appear in the South and Midwest, as well as in less urbanized counties with lower population sizes. Associations between racial inequity and birth center presence underscore the impact of structural racism on perinatal health. Birth center catchment areas are demographically diverse, contrasting the homogenous samples documented in the literature.Public Health Significance: The childbearing populations within the catchment areas of existing birth centers are more racially heterogenous compared to the make-up of clientele cited in the evidence base, highlighting the need for further research to examine the drivers of racially disparate engagement with birth center care.