Reproductive Healthcare Deserts and Maternal and Infant Health - Modified Specific Aims Section Access to reproductive healthcare in the U.S. has become increasingly constrained. A growing body of research has focused on identifying the national- or state-level policies that affect access to care.1–6 Less attention, however, has been paid to documenting access to reproductive healthcare at the local level. This is important because a primary way that policies affect access is through the expansion or contraction of health facilities. Understanding how individuals and local communities experience changes in access to care necessitates a finer-grained measure than the state level, although no data currently exist that would allow for such an approach. Local access to reproductive healthcare, including contraception, maternity, and abortion services, can impact reproductive autonomy and maternal and infant health. “Contraceptive deserts,” or localities with limited or no access to contraception, are becoming more prevalent across the U.S. and threaten women’s ability to time, space, and limit their births.7,8 Access to maternity care is also declining, particularly in rural areas, leading to “maternity care deserts.”9,10 Poor access to maternity services creates barriers to prenatal care and safe delivery, both of which enhance maternal and infant health. Maternity care deserts also complicate postpartum contraceptive use as women often seek information about the best timing for their next pregnancy and contraceptive use after delivery.11 Finally, access to abortion services provides a third pathway to avoid unintended births and their health impacts.12 And yet, living in a county without an abortion provider (“abortion desert”) has become increasingly common.13 Research on contraceptive, maternity, and abortion services is highly siloed, reducing our understanding of whether these care deserts overlap and of the effects of living in a locality lacking services across all three domains, or what is called a “reproductive healthcare desert.” These deserts are likely to overlap geographically and contribute to variations in health outcomes.8,14,15 Building on our team’s expertise in sexual and reproductive health, data integration and management, geospatial science, and robust longitudinal analyses, the aims of the proposed research are to: Aim 1: Create the Reproductive Healthcare Deserts (RHD) longitudinal dataset by combining indicators of access to contraceptive, maternity, and abortion care between 2009-2021 at the U.S. county level. To create this unique dataset, we will integrate data sources on (a) access to publicly funded contraceptive care at Title X clinics from the Office of Population Affairs and at Federally Qualified Health Centers from the Centers for Medicare & Medicaid Services; (b) access to maternity care from the Health Resources and Service Administration; and (c) access to abortion care from the Myers Abortion Facility Database. Aim 2: Use the RHD dataset to document access to reproductive healthcare at the county level between 2009-2021. Working in collaboration with a geospatial data scientist, we will create an interactive dashboard that will map the RHD dataset and include time-varying county-level characteristics obtained from supplementary datasets (e.g., American Community Survey). The dashboard will guide our descriptive research into the spatial patterns and scale of changes to reproductive healthcare access over the study period. Aim 3: Evaluate the relationship between variation in access to reproductive healthcare and individual-level indicators of reproductive autonomy and maternal and infant health. We will merge the RHD dataset with restricted-use data from the National Vital Statistics System and the National Survey of Family Growth to develop spatially clustered multilevel models analyzing the relationship between county-level reproductive healthcare access and individual-level measures of maternal morbidity, infant health, interbirth intervals, co
