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Publication Geographic Access to Labor after Cesarean and Perinatal Outcomes(2024-09) Ranchoff, BrittanyAccess to labor after cesarean (LAC) can be limited, as many clinicians and hospitals do not offer LAC services due to changes in clinical practice guidelines and liability concerns. Prior research suggests that LAC access varies by geography, but these studies are older and limited to a few states. Thus, the extent to which birthing people have access to LAC services in their home county in more recent years across the United States (US) is unknown. In addition, travel distance to perinatal care varies in the US and impacts pregnancy outcomes. Pregnant people who travel farther are at an increased risk of adverse pregnancy outcomes. However, there is paucity of research assessing travel distance to LAC services at the county-level, and whether travel impacts outcomes for people with a prior cesarean seeking vaginal birth after cesarean (VBAC). The three studies in this dissertation aimed to better understand LAC geographic access in the US. The first study described trends across the US in LAC access over time using Natality Restricted-Use Data Files from 2016 to 2021. Counties offering LAC access were unevenly distributed by region, with more LAC-offering counties in the Northeast region versus the South region. After adjusting for other county characteristics, fewer counties had LAC services available over time. The second study examined the association between access to LAC in one’s county of residence and travel for obstetric care among birthing people with one prior birth. Birthing people who did not reside in a LAC-offering county traveled further for delivery than individuals who resided in a LAC-offering county. Additionally, individuals with a prior cesarean traveled slightly further for birth, compared to individuals with a prior vaginal birth. The third study examined whether out-of-county birth and distance traveled among birthing people with LAC are associated with differences in (1) labor induction or augmentation and (2) VBAC. Travel for birth was associated with increased labor induction or augmentation, but similar rates of VBAC, for birthing people with LAC. There were also differences in labor and delivery outcomes for birthing people with LAC in nonmetro versus metro counties. Birthing people with LAC in nonmetro counties had a larger increase in odds of labor induction or augmentation associated with travel for birth, compared to those in metro counties. The overall findings of this dissertation demonstrate barriers to and limited access to LAC services among the US birthing population with a prior cesarean. Furthermore, birthing people must travel farther to find a hospital or clinician who provides LAC. As a result, birthing people may intentionally seek out hospitals or clinicians that align with their preferences regarding LAC. This dissertation provides an understanding that county-level LAC access is essential to create pointed solutions to best meet the needs of birthing people with a prior cesarean, as well as crucial to improving the quality of pregnancy-related care, the birth experience, and birth outcomes in the US.Publication Psychiatric Multimorbidity and Behavioral Health Service Utilization Patterns in Massachusetts(2024-09) Shaffer, PaigeIn the US, the incidence and prevalence of mental health disorders have been on the rise with nearly one in five adults having a psychiatric disorder, and 50% of those with a psychiatric diagnosis having more than one. The US healthcare system is poorly equipped to meet the complex health and social needs of patients with multiple psychiatric disorders. Patients with multiple psychiatric disorders often have poorer functioning, increased health related social needs, and higher healthcare expenditures. There has been a decline in the number of trained specialty providers, such as psychiatrists and psychologists, resulting in a shortage of specialty mental health providers available to provide care for people with multiple psychiatric disorders. However, many mental health conditions are adequately diagnosed and managed by primary care providers. Primary care is well suited for early identification of mental health issues and assessment of needs. Literature that examines patterns of health care utilization and outcomes among patients with psychiatric multimorbidity is scant. Previous research has focused on comorbidity (i.e., only co-occurring pairs of diagnoses, rather than two or more disorders). To fill this gap, this dissertation is comprised of three manuscripts that characterized psychiatric multimorbidity, examined the association between psychiatric multimorbidity and specialty of outpatient care received, and subsequently examined whether psychiatric multimorbidity modifies the association between specialty of outpatient care received and emergency department utilization. Among the 2,409,794 person-years observed in this study, 31.2% had psychiatric multimorbidity. Those with psychiatric multimorbidity were more likely to be women, have serious mental illness, have medical comorbidity, and be enrolled in Medicaid. People with psychiatric multimorbidity were also more likely to receive outpatient mental health specialty care. Receiving outpatient mental health specialty care was associated with a decreased predicted probability of mental health related emergency department use compared to primary care only, and this difference was larger for those with psychiatric multimorbidity. Findings from these studies highlight how common psychiatric multimorbidity is among a statewide population of privately and publicly insured individuals. Findings and a multimorbidity framework have clinical and policy implications for identification and treatment to address psychiatric disorders more comprehensively.