Notice2021-20855
Criteria for Determining Maternity Care Health Professional Target Areas
Primary source
Metadata and text below are from the Federal Register, a public-domain U.S. government work. Always verify the official published version before relying on it for any legal matter.
Published
September 27, 2021
Issuing agencies
Health and Human Services DepartmentHealth Resources and Services Administration
Abstract
In accordance with the requirements of the Public Health Service Act, HRSA, authorized by the Secretary of HHS, shall establish the criteria which will be used to determine maternity care health professional target areas (MCTAs) in existing primary care Health Professional Shortage Areas (HPSAs). This notice sets forth the proposed criteria which will be used to identify and score MCTAs.
Full Text
<html>
<head>
<title>Federal Register, Volume 86 Issue 184 (Monday, September 27, 2021)</title>
</head>
<body><pre>
[Federal Register Volume 86, Number 184 (Monday, September 27, 2021)]
[Notices]
[Pages 53324-53329]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2021-20855]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration
Criteria for Determining Maternity Care Health Professional
Target Areas
AGENCY: Health Resources and Services Administration (HRSA), Department
of Health and Human Services (HHS).
ACTION: Request for public comment.
-----------------------------------------------------------------------
SUMMARY: In accordance with the requirements of the Public Health
Service Act, HRSA, authorized by the Secretary of HHS, shall establish
the criteria which will be used to determine maternity care health
professional target areas (MCTAs) in existing primary care Health
Professional Shortage Areas (HPSAs). This notice sets forth the
proposed criteria which will be used to identify and score MCTAs.
DATES: Submit written comments no later than November 26, 2021.
ADDRESSES: Written comments should be submitted to <a href="/cdn-cgi/l/email-protection#1d4e59504d5d756f6e7c337a726b"><span class="__cf_email__" data-cfemail="7a293e372a3a1208091b541d150c">[email protected]</span></a>.
FOR FURTHER INFORMATION CONTACT: Dr. Janelle McCutchen, Chief, Shortage
Designation Branch, Division of Policy
[[Page 53325]]
and Shortage Designation, Bureau of Health Workforce, HRSA, 5600
Fishers Lane, Rockville, Maryland 20857, (301) 443-9156.
SUPPLEMENTARY INFORMATION: Section 332 of the Public Health Service
Act, 42 U.S.C. 254e, provides that HRSA shall designate HPSAs based on
criteria established by regulation. HPSAs are defined in section 332 to
include (1) urban and rural geographic areas which HRSA determines have
shortages of health professionals, (2) population groups with such
shortages, and (3) public or private medical facilities or other public
facilities with such shortages. The required regulations setting forth
the criteria for designating HPSAs are codified at 42 CFR part 5.
Section 332(k)(1) provides that HRSA shall identify shortages of
maternity care services ``within health professional shortage areas.''
Section 332(k)(1) further requires HRSA to identify MCTAs and
distribute maternity care health professionals within HPSAs using the
MCTAs so identified. HRSA must also collect and publish data in the
Federal Register comparing the availability and need of maternity care
health services in HPSAs and must seek input from relevant provider
organizations and other stakeholders.
HRSA sought input regarding MCTA scoring from relevant stakeholders
via a Request for Information issued in May 2020. HRSA received 24
comments from a variety of stakeholders, including State Primary Care
Offices, Indian tribes, Federally Qualified Health Centers, and women's
health and public health advocacy groups. The comments addressed a wide
range of maternity care concerns, including social determinants of
health that impact maternal health outcomes, women's access to prenatal
care, prevalence of chronic disease, maternity care health professional
provider types to be included in MCTAs, and the maternity care needs of
women in rural areas and among tribes and Alaska natives. Several
commenters also provided suggestions on data sources that HRSA could
use to calculate MCTA scores.
HRSA has carefully reviewed and considered all of the feedback
provided. HRSA proposes the following MCTA scoring criteria, which will
be used to distribute certain currently eligible National Health
Service Corps (NHSC) clinicians who provide maternity care services.
This includes obstetrician gynecologists (OB/GYNs) and certified nurse
midwives (CNMs). The statute does not expand discipline eligibility for
participation in the NHSC to health professionals who are not already
eligible for the NHSC. See section 332(k)(1).
Approach for Determining Maternity Care Health Professional Target
Areas of Greatest Shortage
A MCTA score will be generated for each primary care HPSA using the
HPSA's service area. The following six scoring criteria will be
included in a composite scale that will be used to identify MCTAs with
the greatest shortage of maternity care health professionals: (1) Ratio
of females ages 15-44-to-full time equivalent maternity care health
professional ratio; (2) percentage of females 15-44 with income at or
below 200 percent of the federal poverty level (FPL); (3) travel time
and distance to the nearest provider location with access to
comprehensive maternity care services; (4) fertility rate; (5) the
Social Vulnerability Index; and (6) four maternal health indicators
(pre-pregnancy obesity, pre-pregnancy diabetes, pre-pregnancy
hypertension, and prenatal care initiation in the first trimester).
Each of these six criteria will be assigned a relative weight based on
the significance of that criteria relative to all the others.
The weighted scores will be summed to develop a composite MCTA
score ranging from zero to 25, with 25 indicating the greatest need for
maternity care health professionals in the MCTA. Accordingly, the
higher the composite score, the higher the degree of need for maternity
care health services.
Score for Population-to-Full-Time-Equivalent Maternity Care Health
Professional Ratio
HRSA is seeking public comment on the proposed approach to
measuring the ratio of females ages 15-44-to-full time equivalent (FTE)
maternity care health professional, as HRSA received overwhelmingly
positive stakeholder feedback indicating that HRSA should consider the
population-to-provider ratio as a component of the MCTA score.
Accordingly, population-to-provider ratio will measure the number of
women of childbearing age in the service area compared to the number of
maternity care health professionals in the service area. The
population-to-provider ratio continues to be a cornerstone in measuring
the availability of primary care resources within a particular area.
Based on the available literature and recommendations received, for
purposes of MCTA scoring, women of childbearing age will be defined as
women between the ages of 15-44 years old and maternity care
professionals will be defined as Obstetrician/Gynecologists and
Certified Nurse Midwives (CNMs).\1\ A population-to-provider ratio of
1,500:1 will be used as a minimum requirement for a population to be
considered reasonably served by Obstetrician/Gynecologists and CNMs.\2\
---------------------------------------------------------------------------
\1\ Johantgen, M. et al. ``Comparison of Labor and Delivery Care
Provided by Certified Nurse-Midwives and Physicians: A Systematic
Review, 1990 to 2008.'' Women's Health Issues, vol. 22, no. 1
(2012): e73-e81, doi: 10.1016/j.whi.2011.06.005.
\2\ Rayburn, W.F. et al. ``Distribution of American Congress of
Obstetricians and Gynecologists Fellows and Junior Fellows in
Practice in the United States.'' Obstet Gynecol, vol. 119, no. 5
(2012): 1017, doi: 10.1097/AOG.0b013e31824cfe50.
---------------------------------------------------------------------------
Based on comments received, research, and consultation with
stakeholders, HRSA did not include General Surgeons, Anesthesiologists,
Pediatricians, Doulas, and Lactation Specialists into the provider
portion of the population-to-provider ratio for MCTA scoring, as these
providers do not typically provide full-scope comprehensive maternity
care. Additionally, HRSA considered including Family Medicine
Physicians, Physician Assistants, Advance Practice Registered Nurses,
and Registered Nurses who provide Women's Health services or obstetric
care into the provider portion of the population-to-provider ratio for
MCTA scoring. With respect to Family Medicine Physicians, research
shows that family medicine practitioners offering maternity care
services has been in decline in recent years, and data demonstrating
how much time these providers spend providing maternity care services
is not readily available.
Rayburn, Petterson, and Phillips conducted an observational study
from 2003 to 2010 in which they examined the proportion of Family
Physicians who perform deliveries.\3\ The proportion of Family
Physicians performing deliveries declined by 40.6 percent, from 17.0
percent in 2003 to 10.1 percent in 2009, with deliveries being more
common in nonmetropolitan areas. The researchers concluded that the
proportion of Family Physicians performing deliveries continues to
decline with most delivering Family Physicians performing 25 or fewer
deliveries per year. In another study, Makaroff, et al., evaluated
factors that are contributing to the decline of Family
[[Page 53326]]
Physicians providing maternity care.\4\ Makaroff, et al. evaluated
American Board of Family Medicine survey data collected from every
family physician during application for the Maintenance of
Certification Examination to determine the percentage of family
physicians that provided maternity care from 2000 to 2010. This
research team's findings are in line with the results of the research
conducted by Rayburn, Petterson, and Phillips in that they also found
that maternity care provision by family physicians declined from 23.3
percent in 2000 to 9.7 percent in 2010 (p <0.0001). Furthermore, in
2018, a study from Goldstein, et al. shows that the percentage of
family practitioners offering low and high volume maternity care
services continues to decline in both the United States and Canada and
is now at less than 5 and 1 percent, respectively. These findings are
based on data from the American Board of Family Medicine Examination
questionnaires. The data specifically showed that the number of family
practitioners who offered high volume obstetric services has declined
by 50 percent since 2009.\5\
---------------------------------------------------------------------------
\3\ Rayburn, William F., Stephen M. Petterson, and Robert L.
Phillips. ``Trends in Family Physicians Performing Deliveries, 2003-
2010.'' Birth (Berkeley, Calif.) 41.1 (2014): 26-32.
\4\ Makaroff, Laura A. et al. ``Factors Influencing Family
Physicians' Contribution to the Child Health Care Workforce.''
Annals of family medicine 12.5 (2014): 427-431.
\5\ Goldstein, Jessica, et al., ``Supporting Family Physician
Maternity Care Providers'' Family Medicine 50:9 (2018).
---------------------------------------------------------------------------
Thus, while family physicians continue to play an important role in
providing maternity care in many parts of the United States, there is a
documented decline in the percentage of family physicians providing
maternity care. HRSA recognizes the important contribution all of these
professionals play in the delivery of obstetric care. However, as there
is also not currently detailed nationwide data readily available
outlining the number of hours individual providers provide these
services, HRSA did not have an analytical basis for how to include them
consistently. HRSA will continue to review the availability of these
data points to determine if additional provider types (particularly
Family Medicine Physicians, but also including General Surgeons,
Anesthesiologists, Pediatricians, Doulas, Lactation Specialists,
Physician Assistants, Advance Practice Registered Nurses, and
Registered Nurses who provide Women's Health services) may be
incorporated into the MCTA scoring criteria in the future. HRSA is
especially interested in recommendations for how to determine the
amount of time Family Medicine Physicians spend providing maternity
care services, as they may be the only providers of maternity services
in areas with no OB/GYNs or CNMs. HRSA welcomes comments on how to
incorporate these providers into future iterations of MCTA scoring, and
any detailed nationwide data that may be available to do so.
HRSA is seeking feedback on the assigned point values in the
distribution, which are proposed to be as follows:
------------------------------------------------------------------------
Population-to-provider ratio Points
------------------------------------------------------------------------
Ratio >=6,000:1, or No CNMs or OB-GYNs and Population 5
(Pop) >=500............................................
6,000:1 >Ratio >=5,000:1, or No CNMs or OB-GYNs and Pop 4
>=400..................................................
5,000:1 >Ratio >=3,000:1, or No CNMs or OB-GYNs and Pop 3
>=300..................................................
3,000:1 >Ratio >=2,000:1, or No CNMs or OB-GYNs and Pop 2
>=200..................................................
2,000:1 >Ratio >=1,500:1, or No CNMs or OB-GYNs and Pop 1
>=100..................................................
Ratio <1,500:1, or No CNMs or OB-GYNs and Pop <100...... 0
------------------------------------------------------------------------
Score for Percentage of Population With Income at or Below 200 Percent
of the Federal Poverty Level
HRSA proposes to incorporate poverty data from the U.S. Census
Bureau into the MCTA composite score, as the majority of commenters
highlighted the disparities that women living in poverty face in
accessing necessary maternity health services. The percentage of people
living in the service area at or below 200 percent of the FPL will be
used to score MCTAs, based on recommendations from commenters and
poverty data from the U.S. Census Bureau. Maternal health literature
demonstrates a high correlation between low income, low health status,
and poor maternal health outcomes.\6\
---------------------------------------------------------------------------
\6\ Aftab., et al. ``Effects of Poverty on Pregnant Women.''
Department of Gynae and Obstetrics, Dow University of Health
Sciences, Lyari General Hospital, Karachi, vol. 51, no.1 (2012).
March of Dimes, ``Nowhere to Go: Maternity Care Deserts Across the
US,'' (2018), available at <a href="https://www.marchofdimes.org/materials/Nowhere_to_Go_Final.pdf">https://www.marchofdimes.org/materials/Nowhere_to_Go_Final.pdf</a>.
---------------------------------------------------------------------------
HRSA is seeking feedback on the assigned point values in the
distribution, which are proposed as follows:
------------------------------------------------------------------------
Population with income at or below 200% FPL ratio Points
------------------------------------------------------------------------
Percentage of population with income at or below 200% 6
FPL >=55%..............................................
55% >Percentage of population with income at or below 5
200% FPL >=50%.........................................
50% >Percentage of population with income at or below 4
200% FPL >=45%.........................................
45% >Percentage of population with income at or below 3
200% FPL >=40%.........................................
40% >Percentage of population with income at or below 2
200% FPL >=35%.........................................
35% >Percentage of population with income at or below 1
200% FPL >=30%.........................................
Percentage of population with income at or below 200% 0
FPL <30%...............................................
------------------------------------------------------------------------
Score for Travel Distance/Time to Nearest Source of Accessible Care
Outside of the MCTA
Several of the commenters highlighted the barriers in travel time
and transportation that many women face in accessing maternity care
services, particularly in rural and underserved areas. In keeping with
this feedback, HRSA will incorporate the travel time and distance to
the Nearest Source of Care into the MCTA composite score. The Nearest
Source of Care is defined as the closest provider location where the
residents of the area or designated population have access to
comprehensive maternity care services. Scientific literature presented
by the American Academy of Pediatrics Committee on Fetus and Newborn
and the American College of Obstetricians
[[Page 53327]]
and Gynecologists Committee on Obstetric Practice established that an
individual's proximity to care can affect health outcomes.\7\
Specifically for maternity care, the literature indicates that
decision-to-incision time for emergency cesarean delivery is 30
minutes.\8\
---------------------------------------------------------------------------
\7\ Kilpatrick, Sarah J., et al. Guidelines for Perinatal Care.
8th ed., American Academy of Pediatrics, 2017.
\8\ Roa, Lina et al., ``Travel Time to Access Obstetric and
Neonatal Care in the United States.'' Obstetrics and Gynecology (New
York. 1953) vol. 136, no. 3 (2020): 610-612.
---------------------------------------------------------------------------
HRSA is seeking public comment on the assigned point values in the
distribution, which are proposed as follows:
------------------------------------------------------------------------
Travel time and distance Points
------------------------------------------------------------------------
Time >=105 min, or Distance >=105 miles................. 6
105 min >Time >=90 min or 105 miles > Distance >=90 5
miles..................................................
90 min >Time >=75 min, or 90 miles > Distance >=75 miles 4
75 min >Time >=60 min, or 75 miles > Distance >=60 miles 3
60 min >Time >=45 min, or 60 miles > Distance >=45 miles 2
45 min >Time >=30 min, or 45 miles > Distance >=30 miles 1
Time <30 min, and Distance <30 miles.................... 0
------------------------------------------------------------------------
Score for Fertility Rate
HRSA proposes to include fertility rate as a criteria for the MCTA
score to reflect the increased need for maternity care services among
populations which experience a higher rate of births. Women of
childbearing age will be derived from the American Community Survey and
births will be derived from the National Vital Statistics System.
HRSA is seeking public comment on the assigned point values in the
distribution, which are proposed as follows:
------------------------------------------------------------------------
Fertility rate Points
------------------------------------------------------------------------
Fertility Rate >=90th Percentile........................ 2
90th Percentile >Fertility Rate >=50th Percentile....... 1
Fertility Rate <50th Percentile......................... 0
------------------------------------------------------------------------
Score for Social Vulnerability Index
Several MCTA commenters highlighted associations between adverse
maternal health outcomes and non-clinical factors such as poverty,
unemployment, lack of adequate housing and transportation, minority
status, and English language proficiency. The Agency for Toxic
Substances and Disease Registry's Geospatial Research, Analysis and
Services Program within the Centers for Disease Control and Prevention
(CDC) created databases to help emergency response planners and public
health officials identify and map communities that will most likely
need support before, during, and after a hazardous event. Per the CDC,
Social Vulnerability refers to the resilience of communities when
confronted by external hazards such as natural or human-caused
disasters, or disease outbreaks.
One such database is the Social Vulnerability Index (SVI), which
uses U.S. Census data to determine the social vulnerability of every
census tract based on the following four themes: Socioeconomic status,
household composition and disability, minority status and language, and
housing type and transportation. Each tract receives a separate
percentile ranking which is represented by a number between zero and
one for each of the four themes, as well as an overall ranking. These
themes take into account various factors ranging from educational
attainment and unemployment to multi-unit structures and single parent
households.
Public health literature supports the correlation between low
English proficiency and late initiation of prenatal care as well as
adverse perinatal outcomes due to lack of communication between the
provider and patient.<SUP>9 10</SUP> Currently, literature is not
available that evaluates the use of the entire SVI to specifically
quantify maternal health outcomes. However, many of the individual
factors within the SVI are known social determinants of health. Social
determinants of health are the conditions in the environment in which
people are born, live, learn, work, play, worship, and age that affect
a wide range of health, functioning, and quality-of-life outcomes and
risks. These social determinants of health as represented within the
SVI, are critical in understanding external factors that affect the
need for maternity care services.
---------------------------------------------------------------------------
\9\ Pope, Charlene. ``Addressing Limited English Proficiency and
Disparities for Hispanic Postpartum Women.'' Journal of Obstetric,
Gynecologic & Neonatal Nursing, vol. 34, no. 4, 2005, pp. 512-20.
Crossref, doi:10.1177/0884217505278295.
\10\ Vinson, Abigail, et al. ``131: Maternal Language, Severe
Maternal Morbidity and Access to Prenatal Care.'' American Journal
of Obstetrics and Gynecology, vol. 222, no. 1, 2020, pp. S99-100.
Crossref, doi:10.1016/j.ajog.2019.11.147.
---------------------------------------------------------------------------
A score for overall social vulnerability will be incorporated into
the MCTA composite score to reflect the increased need for maternity
care services among populations which experience a higher rate of
social vulnerability using the CDC's SVI. HRSA is seeking public
comment on the assigned point values in the distribution, which are
proposed as follows:
------------------------------------------------------------------------
Social Vulnerability Index Points
------------------------------------------------------------------------
Social Vulnerability >=75th Percentile.................. 2
75th Percentile > Social Vulnerability >=50th Percentile 1
Social Vulnerability <50th Percentile................... 0
------------------------------------------------------------------------
[[Page 53328]]
Score for Maternal Health Indicators
Many of the comments HRSA received raised concerns about social
determinants of health that have an impact on women's health outcomes,
not only during and after pregnancy, but also before and in between
pregnancies. In order to address these concerns, HRSA is seeking public
comment on the use of maternal health indicators as scoring criteria
for MCTAs. MCTA scores will consider health indicators that are
associated with poor maternal health outcomes by looking at various
data points related to pre-pregnancy health status and when prenatal
care began. Scores will consider pre-pregnancy obesity, diabetes, and
hypertension, as well as whether prenatal care began in the first
trimester, as these are all conditions which may require additional
workforce capacity to adequately address community needs. Only women of
childbearing age will be considered for these indicators. HRSA will use
the National Vital Statistics System as the data source to determine
the sub-score for each of these four (4) maternal health indicators.
Public health literature demonstrates that higher rates of obesity,
diabetes, or hypertension, and later onset of prenatal care are all
associated with poorer maternal health outcomes and will help identify
the need for additional health professionals. A 2018 Centers for
Disease Control and Prevention report on preconception health
surveillance identified priority indicators for adverse maternal health
outcomes.\11\ The study reviewed 50 preconception health indicators and
prioritized those indicators that are most suitable for surveillance
purposes. Weight, diabetes, and hypertension were all among the top 10
preconception health indicators recommended for surveillance.\12\
---------------------------------------------------------------------------
\11\ Robbins, Cheryl L., et al. ``Preconception Health
Indicators for Public Health Surveillance.'' Journal of Women's
Health, vol. 27, no. 4 (2018): 430-43.
\12\ Ibid.
---------------------------------------------------------------------------
HRSA also considered incorporating maternal mortality data into the
MCTA score. However, due to data suppression for privacy reasons, this
data is not readily available publicly or to HRSA below the state
level. As both HPSAs and MCTAs are designed to be able to provide
meaningful differentiation of need between communities at a local
level, HRSA decided not to incorporate maternal mortality data at this
time. If this data eventually becomes available to HRSA at the county
level or below, HRSA may include it in future MCTA score calculation.
HRSA is seeking public comment on the proposed criteria and point
scale distributions below. Service areas may receive one point each for
meeting the criteria.
<bullet> Pre-Pregnancy Obesity
Pre-pregnancy obesity is defined as having a Body Mass Index of 30
or higher. One point will be awarded if the prevalence of pre-pregnancy
obesity in the area is greater than or equal to the 75th percentile
among all counties in the United States. If the prevalence of pre-
pregnancy obesity in the area is less than the 75th percentile among
all counties, zero points will be awarded.
------------------------------------------------------------------------
Pre-pregnancy obesity Points
------------------------------------------------------------------------
Prevalence of pre-pregnancy obesity >=75th percentile... 1
Prevalence of pre-pregnancy obesity <75th percentile.... 0
------------------------------------------------------------------------
<bullet> Pre-Pregnancy Diabetes
One point will be awarded if the prevalence of pre-pregnancy
diabetes in the area is greater than or equal to the 75th percentile
among all counties in the United States. If the prevalence of pre-
pregnancy diabetes in the area is less than the 75th percentile among
all counties, zero points will be awarded.
------------------------------------------------------------------------
Pre-pregnancy diabetes Points
------------------------------------------------------------------------
Prevalence of pre-pregnancy diabetes >=75th percentile.. 1
Prevalence of pre-pregnancy diabetes <75th percentile... 0
------------------------------------------------------------------------
<bullet> Pre-Pregnancy Hypertension
One point will be awarded if the prevalence of pre-pregnancy
hypertension among women in the area is greater than or equal to the
75th percentile among all counties in the nation. If the prevalence of
pre-pregnancy hypertension among women in the area is less than the
75th percentile among all counties, zero points will be awarded.
------------------------------------------------------------------------
Pre-pregnancy hypertension Points
------------------------------------------------------------------------
Prevalence of pre-pregnancy hypertension >=75th 1
percentile.............................................
Prevalence of pre-pregnancy hypertension <75th 0
percentile.............................................
------------------------------------------------------------------------
<bullet> Prenatal Care Initiation in the 1st Trimester
One point will be awarded if the prevalence of women who did not
initiate prenatal care in the first trimester of their pregnancy is
greater than or equal to the 75th percentile among all counties in the
nation. Zero points will be awarded if the prevalence of women who did
not initiate prenatal care in the first trimester of their pregnancy is
less than the 75th percentile among all counties.
------------------------------------------------------------------------
Prenatal care in first trimester Points
------------------------------------------------------------------------
Prevalence of No Prenatal Care in First Trimester >=75th 1
percentile.............................................
Prevalence of No Prenatal Care in First Trimester <75th 0
percentile.............................................
------------------------------------------------------------------------
[[Page 53329]]
Diana Espinosa,
Acting Administrator.
[FR Doc. 2021-20855 Filed 9-24-21; 8:45 am]
BILLING CODE 4165-15-P
</pre><script data-cfasync="false" src="/cdn-cgi/scripts/5c5dd728/cloudflare-static/email-decode.min.js"></script></body>
</html>Indexed from Federal Register on September 27, 2021.
This is legal information, not legal advice. Laws vary by jurisdiction and change frequently. Always verify current law with official sources and consult a licensed attorney in your jurisdiction for advice on your specific situation.