Descriptive Overview of the State
California is the largest state by population size and the third largest state by land area, behind Texas and Alaska, in the nation.[1],[2] California is bordered by Oregon to the north, Mexico to the south, Nevada and Arizona to the east, and the Pacific Ocean to the west. It is divided into 58 counties ranging in size from under 50 square miles in San Francisco to over 20,000 square miles in San Bernardino.[3] These counties – along with three designated cities – make up the 61 local health jurisdictions (LHJs) in the state. Given the vast size of California, the distance that some individuals, especially those living in rural counties, must travel to receive health care services can be a significant challenge. Traveling by car from the northern to the southern border takes three days to cover about 800 miles.
An estimated 40.1 million people reside in California. The state’s population is projected to increase to 43.6 million by 2030. About 36% of all counties are expected to experience a population increase of 10% or more. By 2030, eleven counties will have a population size of over a million residents. Los Angeles will be home to 26% of the state’s population.[4]
Residents who identify as Hispanic account for 39% of the state’s population. This is followed by residents who identify as White (38%), Asian (13%), and Black (6%). Residents identified as multi-racial account for less than 3%.[5]
The number of births in California has been gradually declining over the last five years from 494,392 in 2013 to 454,239 in 2018, a decrease of 8.1%.[6] The state’s number of children ages 19 and below has been declining slowly between 2013 and 2018. There were 2.5 million young children (under age 5) in 2013 representing 6.5% of California’s population. By 2018, this number dropped to 2.4 million representing a 3.2% decline. The number of children ages 5-19, roughly about 8 million in 2013, declined by 0.5% in 2018.[7]
Nearly 8 million women of reproductive age (15 to 44 years) reside in the state. This number is projected to increase to nearly 8.3 million by 2030, representing an increase of nearly 4%. Most of this growth will be among women in the 25-to-39 age group (5%) followed by those in the 40-to-44 age group (4%).[8] Average age of first birth is gradually increasing from 26.9 years in 2013 to 28.1 years in 2018.[9]
California is home to more than 10 million immigrants. The largest numbers of immigrants come from Mexico followed by China and the Philippines. In five counties, foreign-born residents account for over 30% of the population.[10] An estimated 2.4 to 2.6 million undocumented immigrants reside in the state. The size of the undocumented population ranges from about 1,500 in Humboldt County to 9,000 in San Luis Obispo County and 248,000 in Orange County.[11]
Approximately 16.6 million residents aged five and over speak a language other than English at home.[12] This represents a 9% increase since 2010 and a 233% increase since 1980.[13] Based on a special tabulation by the U.S. Census, more than 200 languages are spoken at home in California. One out of five residents who speak a different language other than English at home do not speak English well or do not speak English at all,[14] underscoring the need for linguistically appropriate health services and outreach.
The California economy is the largest in the country accounting for $3 trillion dollars or 15% of the nation’s gross domestic product. The state’s economic output in 2018 was the fifth largest in the world.[15] It has grown by an average of nearly 3% per year since 2010.[16] There are still great disparities in wealth distribution between households in California.[17] For instance, the median net worth of college-educated Black residents is about $68,200 compared with a medium net worth of $397,100 for college-educated White residents.[18] Median family income at the bottom 10th percentile range is about $23,000, while family income at the top 90th percentile range is about $239,000.[19]
An estimated 5.0 million residents live below the federal poverty level. This represents nearly 13% of the state’s population. However, several population subgroups experience a higher proportion of poverty. A greater proportion of residents identified as Black (19%) or Hispanic (17%) live in poverty than residents identified as Asian (10%) or White (9%). At the same time, a greater proportion of children under the age of 18 years (18%) live in poverty than adults 18 to 34 years (15%) or adults 35 to 64 years (11%).[20] At the local level, the poverty rate in 12 counties is at least five percentage points greater than the state average.[21] The California Poverty Measure is an index which expands conventional poverty measures by accounting for costs associated with living expenditures and family resources.[22] Based on this index, about 18% of residents are estimated to live in poverty, 5% of which live in deep poverty.
Food insecurity is defined as a household-level economic and social condition of limited or uncertain access to adequate food.[23] Food insecurity can have devastating effects on pregnant women and young children. Women experiencing food insecurity during pregnancy are more likely to experience birth complications than women who are food-secure. For children, inadequate nutrition can permanently alter brain development, affecting children’s life-long learning, social interactions, and productivity.[24]
An analysis using data from the U.S. Department of Agriculture reveals that 4.3 million persons in California experience food insecurity. This includes 1.6 million children. Counties with the highest rates of child food insecurity include Fresno (25%) and Merced (24%).[25] While recent figures show that the prevalence of household food insecurity had decreased by two percentage points over the past few years,[26] we can anticipate a substantial increase due to the COVID-19 public health emergency and economic crisis.
There are over 1,000 public school districts located throughout the state serving 6.2 million students.[27] Approximately 45.0% of public-school students are in elementary school (Grades 1-6) and 35.1% are in high school (Grades 9-12). There are 23 campuses belonging to the California State University system and 10 campuses belonging to the University of California system.[28],[29] There are 115 campuses belonging to the California Community College system.[30] Collectively, these systems teach about 2.9 million college-age students each year.
California ranks 42nd in the percent of students served under the Individuals with disabilities education act (12.2%) but continues to serve the largest number of children. This number has increased by 19% from about 468,000 in 1990-91 to about 768,000 in 2017-18. California served approximately 11.0% of all children (ages 0-21) covered by the Individuals with Disabilities Education Act nationally.[31]
Ecology
California is very geographically diverse, with many different climates and native plants and animals unique to the state. This geographic diversity lends itself to a host of natural assets – mountains, lakes, coastal areas, deserts and ideal agricultural conditions – as well as a range of natural disasters including wildfires, floods and earthquakes. California’s ecology and the increasing frequency of climate-related natural disasters are directly influenced by climate change.[32] Half of the most destructive wildfires in the state’s history have occurred since 2015.[33]
California has one of the most severe shortages in affordable housing across the county. The median price of a single-family home in California is two times greater than the median U.S. home price. Only 31% of all households in the state can afford to purchase a house, although this differs by county.[34] The California Department of Housing and Community Development projects that there will continue to be severe housing issues. From 2015 to 2025, about 1.8 million new housing units will be needed to meet the projected growth in population and household. The demand for housing will be compounded by both the expected growth in the state population and the expected growth in the size of individual households.[35]
According to a congressional report by the U.S. Department of Housing and Urban Development, an estimated 151,000 persons were homeless in California during a single night in January 2019. This represents an increase of 16% from 2018. About 13% of all homeless people were families with children. Another eight percent were children unaccompanied by a parent or guardian.[36] LGBT youth are significantly overrepresented in homeless populations compared with their proportion of the U.S. population. Analyses of available data have found that approximately 1.6 million (an estimated 1 in 7) U.S. youth ages 12 to 17 ran away from home and experienced at least one night of homelessness in 2002.[37] According to another report funded by the U.S. Department of Health and Human Services, about 30% of youth who leave home in California are “on the street” based on data collected from crisis-related calls and other communications to the National Runaway Safeline. This includes children who were forced to leave their home by their parent-guardian, children who were considered to run away, and children who were homeless because their family is also homeless.[38],[39]
About 2.8 million residents – or 7% of the state population – do not have health insurance coverage.[40] This includes about 291,000 children age 0 to 18 years and 753,000 adults with dependent children.[41],[42] The population groups with the highest rates of uninsured status include residents identified as Hispanics (12%) and non-elderly adults (10%).[43] According to the California Department of Public Health (CDPH)/Maternal, Child and Adolescent Health (MCAH) Division’s Maternal and Infant Health survey, about one in five pregnant women are uninsured in the months before pregnancy, and another 13% of pregnancy women are uninsured in the months after pregnancy.[44]
There are about 12.8 million Medicaid-certified eligible persons in the state. This includes 5.3 million children between the ages of 0 and 20 years. Most of the eligible persons (82%) are served under its managed care program.[45] Survey data from the California Health Interview Survey (CHIS) reports that 42.6% of infants and children (ages 0-18) were on Medicaid in 2018.[46]
The Patient Protection and Affordable Care Act has reduced the number of uninsured residents in the state. Overall, there was an 11% decrease in the rate of uninsured non-elderly persons from 19% in 2013 to 8% in 2017.[47] However, rates of uninsured individuals and families are likely to grow as a result of COVID-19 related job loss and economic challenges.
Substance Use
Substance use among pregnant women in California is well below average compared to national statistics, however, the number of pregnant women with opioid use disorder at labor and delivery increased 33% from 1999 to 2011 (most recent year available).[48] Among adolescents (12-19), findings from the National Survey on Drug Use and Health reported that California ranked 17th highest nationally, with 4.6% of the adolescent population being dependent on or having abused illicit drugs or alcohol in the past year.[49]
Tobacco use among pregnant women is lowest in California, at 1.4% in 2017. Additionally, tobacco use among adolescents is the second lowest nationally in California at 3.5%, following the state with the lowest level of adolescent smoking, Hawaii.[50]
Government Structure
California’s governmental structure is composed of three branches: the legislative, the executive, and the judicial. The executive branch is responsible for administering and enforcing the laws of California. The executive branch houses more than 100 offices, agencies, and departments. One of these agencies is the California Health and Human Services (CHHS) Agency. This agency contains 18 individual departments/offices, including CDPH. The California Department of Health Care Services, which manages Medicaid, is a sister department within CHHS.
That state’s governmental structure is also divided into counties. For the purposes of administering CDPH/MCAH programs, the California Health and Safety Code goes further to divide the government structure by county health departments or combined health departments collectively referred to as local health jurisdictions.[51] In California, 61 LHJs directly administer CDPH/MCAH programs within their regions.
Systems of Care
The California Office of Statewide Health Planning reports that an estimated 16.6 million residents live in locations designated as having a workforce shortage of health care providers. This includes 8.6 million living in areas with a shortage of primary care providers, 6.2 million living in areas with a shortage of mental health providers, and 1.8 million living in areas with a shortage of dental health providers.[52]
There are about 6,900 licensed healthcare facilities in the state. These facilities include 445 general acute care hospitals, 1,406 community clinics, 46 free clinics, and 38 acute psychiatric hospitals. There are 243 hospitals licensed for labor and delivery and 11 alternative birthing centers. The ten largest acute care hospitals are located in the following eight counties: Fresno, Los Angeles, Orange, San Diego, San Francisco, Santa Clara, Sonoma, and Tulare. Each of these facilities has a capacity of more than 600 beds.[53]
According to the Children’s Hospital Association, there are 22 children’s hospitals located throughout California.[54] These hospitals are located within 10 counties across the state. Although most counties do not have a designated children’s hospital to provide pediatric care, many counties have arrangements to refer pediatric clients to the nearest children’s hospitals in the region.
According to the March of Dimes, fourteen counties have no hospitals offering obstetric care. Another 14 counties have only one hospital to serve the entire county.[55] This is particularly consequential for pregnant women considering a recent finding showing that traveling more than 50 miles to prenatal care is associated with increased likelihood of high blood pressure during pregnancy. [56]
The connections between transportation and public health are numerous and varied, touching on physical activity, walkability and safe streets, injury, air quality, and differential access to services including health care. For example, the Los Angeles Mommy and Baby Study determined that poor geographic accessibility to care was associated with travel burdens for pregnant women.[57]
In California, access issues can be complicated, given the geographic diversity and distribution of providers. All of these factors present a number of unique challenges to implementing Local MCAH programs, particularly among those located in rural areas where they might face issues related to staff recruitment, provider shortages, long distances to conduct home visits and other region-specific challenges.
[1] U.S. Bureau of the Census. ACS Demographic and Housing Estimates, 2013-2017 American Community Survey 5-Year Estimates. https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_17_5YR_DP05&src=pt. Accessed January 4, 2019.
[2] U.S. Bureau of the Census. GCT-PH1. Population Housing Units, Area, and Density: 2010: United States – States: and Puerto Rico 2010 Census Summary File 1. https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=bkmk. Accessed January 4, 2019.
[3] California State Association of Counties. Square Mileage by County. http://www.counties.org/pod/square-mileage-county. Accessed January 4, 2019.
[4] California Department of Finance. P-1 County Population Projections 2010-2060, Total Population by County. http://www.dof.ca.gov/Forecasting/Demographics/Projections/. Published May 2019. Accessed October 21, 2019.
[5] California Department of Finance. P-1 County Population Projections 2010-2060, Total Population by Race/Ethnicity. http://www.dof.ca.gov/Forecasting/Demographics/Projections/. Published May 2019. Accessed October 21, 2019.
[6] 2013 Birth Statistical Master File and 2018 California Comprehensive Master Birth File; based on California resident births.
[7] California Department of Finance. Demographic Research Unit. 2020. State and county population projections 2010-2060 [P-3: State and County Projections Dataset]. Sacramento: California Department of Finance. January 2020.
[8] California Department of Finance. P-1 State Population Projections, 2010-2060, Total Population by Sex and Age Group. http://www.dof.ca.gov/Forecasting/Demographics/Projections/. Published May 2019. Accessed October 25, 2019.
[9] 2013 Birth Statistical Master File and 2018 California Comprehensive Master Birth File; based on California resident first births; excludes births with unknown maternal age.
[10] Johnson, H., & Sanchez, S. Immigrants in California. Public Policy Institute of California. https://www.ppic.org/wp-content/uploads/jtf-immigrants-in-california.pdf. Published May 2019. Accessed October 11, 2019.
[11] Hayes, J., & Hill, L. Undocumented Immigrants in California. Public Policy Institute of California Website. https://www.ppic.org/content/pubs/jtf/JTF_UndocumentedImmigrantsJTF.pdf. Published March 2017. Accessed January 4, 2019.
[12] U.S. Bureau of the Census. S1603. Characteristics of People by Language Spoken at Home. 2018 American Community Survey 1-Year Estimates. https://data.census.gov/cedsci/table?q=S1603&table=S1603&tid=ACSST1Y2018.S1603&lastDisplayedRow=19&hidePreview=true&g=0400000US06. Accessed October 29, 2019.
[13] Zeigler K, Camarota SA. 67.3 Million in the United States Spoke a Foreign Language at Home in 2018. Center for Immigrant Studies. https://cis.org/Report/673-Million-United-States-Spoke-Foreign-Language-Home-2018. Published October 29, 2019. Accessed November 1, 2019.
[14] U.S. Bureau of the Census. B16004. Age by Language Spoken at Home by Ability to Speak English for the Population 5 Years and Over, 2018 American Community Survey 1-Year Estimates. https://data.census.gov/cedsci/table?q=b16004&lastDisplayedRow=31&table=B16004&tid=ACSDT1Y2018.B16004&hidePreview=false&g=0400000US06&y=2018. Accessed November 13, 2019.
[15] California Department of Finance. Gross State Product, Comparison to other Major Countries. http://www.dof.ca.gov/Forecasting/Economics/Indicators/Gross_State_Product/. Accessed October 11, 2019.
[16] California Department of Finance. Gross State Product, Gross State Product in California. http://www.dof.ca.gov/Forecasting/Economics/Indicators/Gross_State_Product/. Accessed October 11, 2019.
[17] Bohn, S., & Danielson, C. Income inequality and the Safety Net in California. Public Policy Institute of California Website. https://www.ppic.org/content/pubs/report/R_516SBR.pdf. Published May 2016. Accessed January 4, 2019.
[18] California Budget and Policy Center. The Racial Wealth Gap: What California Can Do About a Long-Standing Obstacle to Shared Prosperity? California Budget and Policy Center. https://calbudgetcenter.org/whttps://www.ppic.org/wp-content/uploads/californias-future-january-2019.pdfp-content/uploads/2018/12/Report_The-Racial-Wealth-Gap_12.2018.pdf. Published December 2018. Accessed October 16, 2019.
[19] Public Policy Institute of California. California’s Future. Public Policy Institute of California. https://www.ppic.org/wp-content/uploads/californias-future-january-2019.pdf. Published January 2019. Accessed October 16, 2019.
[20] U.S. Bureau of the Census. S1701. Poverty Status in the Past 12 Months. 2018 American Community Survey 1-Year Estimates. https://data.census.gov/cedsci/table?q=S17&d=ACS%201-Year%20Estimates%20Subject%20Tables&table=S1701&tid=ACSST1Y2018.S1701&lastDisplayedRow=27&hidePreview=true&g=0400000US06&y=2018. Accessed November 13, 2019.
[21] U.S. Bureau of the Census. S1701. Poverty Status in the Past 12 Months. 2018 American Community Survey 1-Year Estimates. https://data.census.gov/cedsci/table?q=S17&d=ACS%201-Year%20Estimates%20Subject%20Tables&table=S1701&tid=ACSST1Y2018.S1701&lastDisplayedRow=27&hidePreview=true&g=0400000US06,06.050000&y=2018&tp=true. Accessed November 13, 2019.
[22] Stanford Center on Poverty and Inequality. California Poverty Measure. https://inequality.stanford.edu/publications/research-reports/california-poverty-measure. Accessed January 4, 2019.
[23] U.S. Department of Agriculture, Economic Research Service. Definitions of Food Security. https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/definitions-of-food-security.aspx. Published September 2019. Accessed October 17, 2019.
[24] Gunderson, C., A. Dewey, M. Kato, A. Crumbaugh & M. Strayer. Map the Meal Gap 2019: A Report on County and Congressional District Food Insecurity in the United States in 2017. Feeding America, 2019. https://www.feedingamerica.org/sites/default/files/2019-05/2017-map-the-meal-gap-full.pdf
[25] Feeding America. Map the Meal Gap 2019: Overall and Child Food Insecurity by County in 2017. https://public.tableau.com/profile/feeding.america.research#!/vizhome/2017StateWorkbook-Public_15568266651950/CountyDetailDataPublic. Accessed October 16, 2019.
[26] Coleman-Jensen, A, Rabbitt MP, Gregory C, and Singh A. 2019. Household Food Security in the United States in 2018. U.S. Department of Agriculture, Economic Research Service. https://www.ers.usda.gov/webdocs/publications/94849/err-270.pdf?v=963.1. Published September 2019. Accessed October 21, 2019.
[27] California Department of Education. Fingertip Facts on Education in California. https://www.cde.ca.gov/ds/sd/cb/ceffingertipfacts.asp. Accessed October 11, 2019.
[28] California State University. Fact Book 2019. https://www2.calstate.edu/csu-system/about-the-csu/facts-about-the-csu/Documents/facts2019.pdf. Accessed October 14, 2019.
[29] University of California. UC System. https://www.universityofcalifornia.edu/uc-system. Accessed October 14, 2019.
[30] California Community Colleges. Key Facts. https://www.cccco.edu/About-Us/Key-Facts. Accessed October 14, 2019.
[31] National Center for Education Statistics. Digest of Education Statistics, Table 204.70. Number and Percent of Children under Individuals with Disabilities Education Act (IDEA), Part B, by Age and State or Jurisdiction: Selected Years, 1990-91 through 2017-18. https://nces.ed.gov/programs/digest/d18/tables/dt18_204.70.asp?current=yes. Accessed November 15, 2019.
[32] Office of Environmental Health Hazard Assessment, California Environmental Protection Agency. Indicators of Climate Change in California. https://oehha.ca.gov/media/downloads/climate-change/report/2018caindicatorsreportmay2018.pdf. Published May 2018. Accessed January 8, 2020.
[33] Governor Newsom Strike Force. Wildfires and Climate Change: California’s Energy Future. https://www.gov.ca.gov/wp-content/uploads/2019/04/Wildfires-and-Climate-Change-California%E2%80%99s-Energy-Future.pdf. Published April 2019. Accessed January 2, 2020.
[34] California Association of Realtors. Housing Affordability Index – Traditional, Q3-2019. https://www.car.org/marketdata/data/haitraditional. Accessed November 19, 2019.
[35] California Department of Housing and Community Development. California’s Housing Future: Challenges and Opportunities Final Statewide Housing Assessment 2025. http://www.hcd.ca.gov/policy-research/plans-reports/docs/SHA_Final_Combined.pdf. Published February 2018. Accessed January 7, 2019.
[36] U.S. Department of Housing and Urban Development, Office of Community Planning and Development. The 2019 Annual Homeless Assessment Report to Congress: Part 1: Point-in-Time Estimates of Homelessness. file:///H:/Research%20Proj-Rep/2020%20Title%20V%20State%20Overview/2020%200100%20US%20HUD%202019%20Homeless%20Report.pdf. Published January 2019. Accessed January 13, 2019.
[37] Ray, N. An Epidemic of Homelessness. National Gay and Lesbian Task Force Policy Institute. 2006
[38] National Runaway Safeline. Crisis Connection Content Data Report for Calendar Year 2017. https://www.1800runaway.org/runaway-statistics/crisis-hotline-online-services-statistics/. Accessed December 4, 2019.
[39] National Runaway Safeline. National Trends on Youth in Crisis in the United States: An Analysis of Trends in Crisis Connections to the National Runaway Safeline over the past decade (2007-2017). https://www.1800runaway.org/wp-content/uploads/2018/11/NRS-2018-Trend-Report_Final.pdf. Published 2018. Accessed December 4, 2019.
[40] Berchick ER, Barnett JC, Upton RD. Current Population Reports, P60-267. Health Insurance Coverage in the United States, 2018. U.S. Bureau of the Census. https://www.census.gov/content/dam/Census/library/publications/2019/demo/p60-267.pdf. Published November 2019. Accessed November 12, 2019.
[41] Henry J. Kaiser Family Foundation. Health Insurance Coverage of Children 0-18. https://www.kff.org/state-category/health-coverage-uninsured/?state=CA. Accessed October 14, 2019.
[42] Henry J. Kaiser Family Foundation. Health Insurance Coverage of Adults with Dependent Children. https://www.kff.org/state-category/health-coverage-uninsured/?state=CA. Accessed October 14, 2019.
[43] U.S. Bureau of the Census. S2702. Selected Characteristics of the Uninsured in the United States, 2018 American Community Survey 1-Year Estimates. California. https://data.census.gov/cedsci/table?q=S2702&table=S2702&tid=ACSST1Y2018.S2702&lastDisplayedRow=26&hidePreview=true&g=0400000US06&y=2018. Accessed November 12, 2019.
[44] California Department of Public Health. Maternal and Infant Health Assessment (MIHA) Survey Data Snapshots, 2013-2015. https://www.cdph.ca.gov/Programs/CFH/DMCAH/MIHA/CDPH%20Document%20Library/2013-2015/Snapshot_ByMaternalAge_2013-2015.pdf. Assessed January 7, 2019.
[45] California Department of Health Care Services. Medi-Cal Monthly Enrollment Fast Facts: Characteristics of the Medi-Cal population as captured by the Medi-Cal Eligibility Data System. https://www.dhcs.ca.gov/dataandstats/statistics/Documents/Fast_Facts_May2019_ADA.pdf. Published May 2019. Accessed October 14, 2019.
[46] AskChis. Covered by Medi-Cal, by year. http://ask.chis.ucla.edu/AskCHIS/tools/_layouts/AskChisTool/home.aspx#/results. Accessed July 29, 2020.
[47] Henry J. Kaiser Family Foundation. Key Facts about the Uninsured Population. http://files.kff.org/attachment//fact-sheet-key-facts-about-the-uninsured-population. Published December 2018. Accessed January 3, 2019.
[48] Source: Haight, S. et al. Opioid Use Disorder Documented at Delivery Hospitalization — United States, 1999–2014. CDC Morbidity and Mortality Weekly Report. Published August 10, 2018, accessed July 29, 2020.
[49] America's Health Rankings analysis of SAMHSA, National Survey on Drug Use and Health, United Health Foundation, AmericasHealthRankings.org, Accessed 2020.
[50] America's Health Rankings analysis of CDC WONDER Online Database, Natality public-use data, United Health Foundation, AmericasHealthRankings.org, Accessed 2020.
[51] California Health and Safety Code. Division 106. Personal Health Care (Including Maternal, Child, and Adolescent) Part 2. Maternal, Child, and Adolescent Health [123225-124250]. http://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=HSC&division=106.&title=&part=2.&chapter=3.&article=6. Accessed January 2, 2019.
[52] California Office of Statewide Health Planning & Development. Primary Care Health Professional Shortage Area (HPSA) - Census Detail. https://data.chhs.ca.gov/dataset/primary-care-health-professional-shortage-area-hpsa-census-detail. Accessed December 19, 2019.
[53] California Office of Statewide Health Planning & Development. Facility Finder. https://oshpd.ca.gov/facility-finder. Published June 30, 2018. Accessed October 11, 2019.
[54] Children’s Hospital Association. Children’s Hospital Directory. https://www.childrenshospitals.org/Directories/Hospital-Directory. Accessed October 11, 2019.
[55] March of Dimes. Nowhere to Go: Maternal Care Deserts Across the U.S. https://www.marchofdimes.org/materials/Nowhere_to_Go_Final.pdf. Published 2018. Accessed October 14, 2019.
[56] Shi, L, MacLeod KE, Zhang D, Wang F, Chao MS. Travel distance to prenatal care and high blood pressure during pregnancy. Hypertension in Pregnancy. 2017, 36(1):70-76.
[57] Lu Shi, Kara E. MacLeod, Donglan Zhang, Fan Wang & Margaret Shin Chao (2017) Travel distance to prenatal care and high blood pressure during pregnancy, Hypertension in Pregnancy, 36:1, 70-76, DOI: 10.1080/10641955.2016.1239733.
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