Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Associations between maternal residential rurality and maternal health, access to care, and very low birthweight infant outcomes



Infant mortality is increased in isolated rural areas. This study compares prenatal factors, access to care, and health outcomes for very-low birthweight (VLBW) infants by degree of maternal residential rurality.


This descriptive population-based retrospective cohort study used the California Perinatal Quality Care Collaborative registry to study VLBW infants. Rurality was assigned as urban, large rural, and small rural/isolated using the Rural Urban Commuting Area codes. We used hierarchical random effect models to test the association of rurality with survival without major morbidity.


The study included 38 614 dyads. VLBW survival without major morbidity decreased with increasing rurality and the relationship remained significant for small rural/isolated areas (OR 0.79, p = 0.03) after adjustment. Birth weight, gestational age, and infant sex were similar across geographic groups.


A rural urban disparity exists for VLBW survival without major morbidity. Our findings generate hypotheses about factors that may be driving these disparities.

This is a preview of subscription content, access via your institution

Access options

Rent or buy this article

Get just this article for as long as you need it


Prices may be subject to local taxes which are calculated during checkout

Data availability

The majority of the data generated or analyzed during this study are included in this published article and the variables used are included in the Appendix. The additional datasets generated during and/or analyzed during the current study are not publicly available due to the California Perinatal Quality Care Collaborative agreements, however, they are available from the corresponding author on reasonable request.


  1. Horbar JD, Carpenter JH, Badger GJ, Kenny MJ, Soll RF, Morrow KA, et al. Mortality and neonatal morbidity among infants 501 to 1500 grams from 2000 to 2009. Pediatrics. 2012;129:1019–26.

    Article  PubMed  Google Scholar 

  2. Shah PS, Sankaran K, Aziz K, Allen AC, Seshia M, Ohlsson A, et al. Outcomes of preterm infants <29 weeks gestation over 10-year period in Canada: a cause for concern? J Perinatol. 2012;32:132–8.

    Article  CAS  PubMed  Google Scholar 

  3. Islam JY, Keller RL, Aschner JL, Hartert TV, Moore PE. Understanding the Short- and Long-Term Respiratory Outcomes of Prematurity and Bronchopulmonary Dysplasia. Am J Respir Crit Care Med. 2015;192:134–56.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Rogers EE, Hintz SR. Early neurodevelopmental outcomes of extremely preterm infants. Semin Perinatol. 2016;40:497–509.

    Article  PubMed  Google Scholar 

  5. Kuint J, Lerner-Geva L, Chodick G, Boyko V, Shalev V, Reichman B. Rehospitalization Through Childhood and Adolescence: Association with Neonatal Morbidities in Infants of Very Low Birth Weight. J Pediatr. 2017;188:135–41.

    Article  PubMed  Google Scholar 

  6. Kuint J, Lerner-Geva L, Chodick G, Boyko V, Shalev V, Reichman B. Type of Re-Hospitalization and Association with Neonatal Morbidities in Infants of Very Low Birth Weight. Neonatology. 2019;115:292–300.

    Article  PubMed  Google Scholar 

  7. Helle N, Barkmann C, Ehrhardt S, Bindt C. Postpartum posttraumatic and acute stress in mothers and fathers of infants with very low birth weight: Cross-sectional results from a controlled multicenter cohort study. J Affect Disord. 2018;235:467–73.

    Article  PubMed  Google Scholar 

  8. Hillemeier MM, Weisman CS, Chase GA, Dyer AM. Individual and community predictors of preterm birth and low birthweight along the rural-urban continuum in central Pennsylvania. J Rural Health. 2007;23:42–8.

    Article  PubMed  Google Scholar 

  9. Anderson JG, Rogers EE, Baer RJ, Oltman SP, Paynter R, Partridge JC, et al. Racial and Ethnic Disparities in Preterm Infant Mortality and Severe Morbidity: A Population-Based Study. Neonatology 2018;113:44–54.

    Article  PubMed  Google Scholar 

  10. Singh GK, Siahpush M. Widening rural-urban disparities in all-cause mortality and mortality from major causes of death in the USA, 1969-2009. J Urban Health. 2014;91:272–92.

    Article  PubMed  Google Scholar 

  11. Ely DM, Driscoll AK, Matthews TJ. Infant Mortality Rates in Rural and Urban Areas in the United States, 2014. NCHS Data Brief. 2017;285:1–8.

  12. Mohamoud YA, Kirby RS, Ehrenthal DB. Poverty, urban-rural classification and term infant mortality: a population-based multilevel analysis. BMC Pregnancy Childbirth. 2019;19:40.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Hansen AC, Slavova S, O’Brien JM. Rural residency as a risk factor for severe maternal morbidity. J Rural Health. 2021;38:161–70.

  14. Kozhimannil KB, Interrante JD, Henning-Smith C, Admon LK. Rural-Urban Differences In Severe Maternal Morbidity And Mortality In The US, 2007-15. Health Aff (Millwood). 2019;38:2077–85.

    Article  PubMed  Google Scholar 

  15. Strutz KL, Dozier AM, van Wijngaarden E, Glantz JC. Birth outcomes across three rural-urban typologies in the Finger Lakes region of New York. J Rural Health: Off J Am Rural Health Assoc Natl Rural Health Care Assoc. 2012;28:162–73.

    Article  Google Scholar 

  16. RUCA Rural Health Research Center University of Washington: L. Gary Hart, PhD, Director; 2006 Available from:

  17. 2010 Rural-Urban Commuting Area Codes, U.S. Department of Agriculture. Economic Research Service.

  18. Igram DD, Franco, SJ. 2013 NCHS urban-rural classification scheme for counties. In: Statistics NCfH, editor. Vital Health Stat; 2014.

  19. Newborn AAoPCoFA. Levels of neonatal care. Pediatrics 2012;130:587–97.

    Article  Google Scholar 

  20. Chung JH, Phibbs CS, Boscardin WJ, Kominski GF, Ortega AN, Needleman J. The effect of neonatal intensive care level and hospital volume on mortality of very low birth weight infants. Med Care. 2010;48:635–44.

    Article  PubMed  Google Scholar 

  21. Lorch SA, Rogowski J, Profit J, Phibbs CS. Access to risk-appropriate hospital care and disparities in neonatal outcomes in racial/ethnic groups and rural-urban populations. Semin Perinatol. 2021;45:151409.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Phibbs CS, Baker LC, Caughey AB, Danielsen B, Schmitt SK, Phibbs RH. Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants. N. Engl J Med. 2007;356:2165–75.

    Article  CAS  PubMed  Google Scholar 

  23. Sparks PJ, McLaughlin DK, Stokes CS. Differential neonatal and postneonatal infant mortality rates across US counties: the role of socioeconomic conditions and rurality. J Rural Health. 2009;25:332–41.

    Article  PubMed  Google Scholar 

  24. Lee HC, Liu J, Profit J, Hintz SR, Gould JB. Survival Without Major Morbidity Among Very Low Birth Weight Infants in California. Pediatrics. 2020;146:e20193865.

  25. Villapiano NL, Winkelman TN, Kozhimannil KB, Davis MM, Patrick SW. Rural and Urban Differences in Neonatal Abstinence Syndrome and Maternal Opioid Use, 2004 to 2013. JAMA Pediatr. 2017;171:194–6.

    Article  PubMed  Google Scholar 

  26. Lisonkova S, Haslam MD, Dahlgren L, Chen I, Synnes AR, Lim KI. Maternal morbidity and perinatal outcomes among women in rural versus urban areas. Cmaj. 2016;188:E456–65.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Harris DE, Aboueissa AM, Baugh N, Sarton C. Impact of rurality on maternal and infant health indicators and outcomes in Maine. Rural Remote Health. 2015;15:3278.

    PubMed  Google Scholar 

  28. Oga EA, Mark K, Coleman-Cowger VH. Cigarette Smoking Status and Substance Use in Pregnancy. Matern Child Health J. 2018;22:1477–83.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Vallejo MC, Shapiro RE, Lippy MW, Lilly CL, Brancazio LR. Independent risk factors for chronic illicit substance use during pregnancy. J Opioid Manag. 2020;16:351–6.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Kozhimannil KB, Hung P, Henning-Smith C, Casey MM, Prasad S. Association Between Loss of Hospital-Based Obstetric Services and Birth Outcomes in Rural Counties in the United States. Jama. 2018;319:1239–47.

    Article  PubMed  PubMed Central  Google Scholar 

  31. O’Hanlon CE, Kranz AM, DeYoreo M, Mahmud A, Damberg CL, Timbie J. Access, Quality, And Financial Performance Of Rural Hospitals Following Health System Affiliation. Health Aff (Millwood). 2019;38:2095–104.

    Article  PubMed  Google Scholar 

  32. Kunz SN, Phibbs CS, Profit J. The changing landscape of perinatal regionalization. Semin Perinatol. 2020;44:151241.

    Article  PubMed  Google Scholar 

  33. Hung P, Casey MM, Kozhimannil KB, Karaca-Mandic P, Moscovice IS. Rural-urban differences in access to hospital obstetric and neonatal care: how far is the closest one? J Perinatol. 2018;38:645–52.

    Article  PubMed  Google Scholar 

  34. Desplanches T, Blondel B, Morgan AS, Burguet A, Kaminski M, Lecomte B, et al. Volume of Neonatal Care and Survival without Disability at 2 Years in Very Preterm Infants: Results of a French National Cohort Study. J Pediatr. 2019;213:22–9.

    Article  PubMed  Google Scholar 

  35. Lasswell SM, Barfield WD, Rochat RW, Blackmon L. Perinatal regionalization for very low-birth-weight and very preterm infants: a meta-analysis. Jama 2010;304:992–1000.

    Article  PubMed  Google Scholar 

  36. Conde-Agudelo A, Díaz-Rossello JL. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Syst Rev. 2016;2016:Cd002771.

    PubMed  PubMed Central  Google Scholar 

  37. Chan G, Bergelson I, Smith ER, Skotnes T, Wall S. Barriers and enablers of kangaroo mother care implementation from a health systems perspective: a systematic review. Health Policy Plan. 2017;32:1466–75.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Kim THM, Campbell-Yeo M, Disher T, Dol J, Richardson B, Bishop T, et al. Caregiver presence and involvement in a Canadian neonatal intensive care unit: An observational cohort study. J Pediatr Nurs. 2021;60:123–9.

    Article  PubMed  Google Scholar 

  39. Kamphorst K, Brouwer AJ, Poslawsky IE, Ketelaar M, Ockhuisen H, van den Hoogen A. Parental Presence and Activities in a Dutch Neonatal Intensive Care Unit: An Observational Study. J Perinat Neonatal Nurs. 2018;32:E3–10.

    Article  PubMed  Google Scholar 

  40. The International Classification of Retinopathy of Prematurity revisited. Arch Ophthalmol. 2005;123:991–9.

  41. Patel RM, Ferguson J, McElroy SJ, Khashu M, Caplan MS. Defining necrotizing enterocolitis: current difficulties and future opportunities. Pediatr Res. 2020;88:10–5.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Starr R, De Jesus O, Shah SD, Borger J. Periventricular Hemorrhage-Intraventricular Hemorrhage. StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2021, StatPearls Publishing LLC.; 2021.

Download references


Funding was awarded by the Pratt Foundation.

Author information

Authors and Affiliations



All authors (DSO, JL, JP, BH, EHC) made substantial contributions to the conception or design of the work, or the acquisition, analysis, or interpretation of data. DSO drafted the work, all authors revised it critically for important intellectual content. All authors approved the final version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Devlynne S. Ondusko.

Ethics declarations

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Ondusko, D.S., Liu, J., Hatch, B. et al. Associations between maternal residential rurality and maternal health, access to care, and very low birthweight infant outcomes. J Perinatol 42, 1592–1599 (2022).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


Quick links