Author ORCID Identifier

Date Available


Year of Publication


Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation


Arts and Sciences



First Advisor

Dr. Carrie Oser

Second Advisor

Dr. Mairead Moloney


Cases of severe maternal morbidity (SMM) and pregnancy-related mortality (PRM) are increasing in the US. Research concerning SMM and PRM has neglected women in Central Appalachia; a largely rural, health-disparate population. The aims of this study are two-fold: (1) Examine patient-level and place-based predictors of SMM/PRM via hierarchical logistic regression modeling, and (2) Elucidate Appalachian healthcare patients’ and providers’ experiences with SMM/PRM, perceptions of contributing factors, and insights on points of intervention.

This study uses a mixed methods approach guided by the WHO’s conceptual framework for action on social determinants of health to identify determinants of SMM and PRM among Appalachian women. Aim 1 involved hierarchical logistic regression modeling to assess patient-level and regional predictors of SMM and PRM using the MarketScan Research Database. Aim 2 involved 30 qualitative interviews with Appalachian participants: 10 patients with histories of SMM, 10 providers, and 10 emergency medical technicians (EMTs).

Quantitative results demonstrate patient-level chronic diseases and regional measures of economic security as predictive of SMM. Qualitative results echoed the effect of regional economic hardship on maternal health. Participants expressed a link between changes in the socioeconomic landscapes of their communities and more proximal determinants of maternal health, including patient nutritional status, chronic disease burden, and underutilization of healthcare. Patients with histories of SMM pointed to geographic constraints in healthcare resources and biases within healthcare surrounding patients’ reflections of class. Participants identified many points of intervention, including collaborations between EMS and obstetric care providers, partnerships with local school systems to introduce comprehensive health education curricula, and expansion of community paramedics programs.

Findings warrant further investigation into how regional economic policy may influence maternal health outcomes among women living in economically insecure regions. Findings highlight the need for medical stewardship. Additionally, results reflect how current care-delivery models for medically and socially complex patients may be inadequate for women in rural communities.

Digital Object Identifier (DOI)

Funding Information

This study was supported by a Ruth L. Kirschstein Individual Predoctoral F30 Fellowship from the National Institute of Child Health and Human Development (Hansen, 5F30HD103319) from 2020-2022. Additional support was provided by the University of Kentucky Women in Medicine and Science Booster Award in 2021 and the Substance Use Priority Research Area Graduate Student Award in 2021.