Skip to main content

Thank you for visiting nature.com. 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.

Perinatal outcomes for rural obstetric patients and neonates in rural-located and metropolitan-located hospitals

Abstract

Objective

To compare rural obstetric patient and neonate characteristics and outcomes by birth location.

Methods

Retrospective observational cohort study of rural residents’ hospital births from California, Pennsylvania, and South Carolina. Hospitals in rural counties were rural-located, those in metropolitan counties with ≥10% of obstetric patients from rural communities were rural-serving, metropolitan-located, others were non-rural-serving, metropolitan-located. Any adverse obstetric patient or neonatal outcomes were assessed with logistic regression accounting for patient characteristics, state, year, and hospital.

Results

Of 466,896 rural patient births, 64.3% occurred in rural-located, 22.5% in rural-serving, metropolitan-located, and 13.1% in non-rural-serving, metropolitan-located hospitals. The odds of any adverse outcome increased in rural-serving (aOR 1.27, 95% CI 1.10–1.46) and non-rural-serving (aOR 1.35, 95% CI 1.18–1.55) metropolitan-located hospitals.

Conclusion

One-third of rural obstetric patients received care in metropolitan-located hospitals. These patients have higher comorbidity rates and higher odds of adverse outcomes likely reflecting referral for higher baseline illness severity.

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

Access options

Buy article

Get time limited or full article access on ReadCube.

$32.00

All prices are NET prices.

Fig. 1: Unadjusted and adjusted odds of adverse perinatal outcomes by hospital-serving status.

Data availability

Data generated and analyzed during the current study are not publicly available due to data use agreements, but may be available from the senior author on reasonable request.

References

  1. Ratcliffe M, Burd C, Holder K, Fields A. Defining Rural at the U.S. Census Bureau. 2016. http://www2.census.gov. Accessed 5 April 2021.

  2. National Advisory Committee on Rural Health and Human Services. Maternal and obstetric care challenges in rural America: policy brief and recommendations to the secretary. 2020. https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/rural/publications/2020-maternal-obstetric-care-challenges.pdf. Accessed 14 July 2021.

  3. Maron D. Maternal health care is disappearing in Rural America. Sci Am. 2016. https://www.scientificamerican.com/article/maternal-health-care-is-disappearing-in-rural-america/#. Accessed 29 Mar 2022.

  4. Ely DM, Hoyert DL. Differences between rural and urban areas in mortality rates for the leading causes of infant death: United States, 2013–2015. NCHS Data Brief. 2018;300:1–8.

  5. Womack LS, Rossen LM, Hirai AH. Urban-rural infant mortality disparities by race and ethnicity and cause of death. Am J Prev Med. 2020;58:254–60.

    Article  Google Scholar 

  6. Ehrenthal DB, Daphne Kuo HH, Kirby RS. Infant mortality in rural and nonrural counties in the United States. Pediatrics. 2020;146:e20200464.

  7. Grünebaum A, McCullough LB, Orosz B, Chervenak FA. Neonatal mortality in the United States is related to location of birth (hospital versus home) rather than the type of birth attendant. Am J Obstet Gynecol. 2020;223:254.e1–254.e8.

    Article  Google Scholar 

  8. 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.

    CAS  Article  Google Scholar 

  9. 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  Google Scholar 

  10. Lorch SA, Baiocchi M, Ahlberg CE, Small DS. The differential impact of delivery hospital on the outcomes of premature infants. Pediatrics. 2012;130:270–8.

    Article  Google Scholar 

  11. Kozhimannil KB, Interrante JD, Tuttle MKS, Henning-Smith C. Changes in hospital-based obstetric services in rural US counties, 2014-2018. JAMA. 2020;324:197.

    Article  Google Scholar 

  12. Handley SC, Passarella M, Herrick HM, Interrante JD, Lorch SA, Kozhimannil KB, et al. Birth volume and geographic distribution of US hospitals with obstetric services from 2010 to 2018. JAMA Netw Open. 2021;4:1–12.

    Article  Google Scholar 

  13. Kaufman BG, Thomas SR, Randolph RK, Perry JR, Thompson KW, Holmes GM, et al. The rising rate of rural hospital closures. J Rural Health. 2016;32:35–43.

    Article  Google Scholar 

  14. Lorch SA, Srinivas SK, Ahlberg C, Small DS. The impact of obstetric unit closures on maternal and infant pregnancy outcomes. Health Serv Res. 2013;48:455–75. 2 PART1

    Article  Google Scholar 

  15. 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  Google Scholar 

  16. Aubrey-Bassler F, Cullen R, Simms A, Asghari S, Crane J, Wang PP, et al. Population-based cohort study of hospital delivery volume, geogrpahic accessibility, and obstetric outcomes. Int J Gynecol Obstet. 2019;146:95–102.

    Article  Google Scholar 

  17. Burris HH, Passarella M, Handley SC, Srinivas SK, Lorch SA. Black-White disparities in maternal in-hospital mortality according to teaching and Black-serving hospital status. Am J Obstet Gynecol. 2021;225:e1–9.

    Article  Google Scholar 

  18. Kozhimannil KB, Casey MM, Hung P, Prasad S, Moscovice IS. Location of childbirth for rural women: implications for maternal levels of care. Am J Obstet Gynecol. 2016;214:661.e1–661.e10.

    Article  Google Scholar 

  19. Ryan GM. Toward improving the outcome of pregnancy recommendations for the regional development of perinatal health services. Obstet Gynecol. 1975;46:375–84.

    PubMed  Google Scholar 

  20. Okoroh EM, Kroelinger CD, Lasswell SM, Goodman DA, Williams AM, Barfield WD. United States and territory policies supporting maternal and neonatal transfer: review of transport and reimbursement. J Perinatol. 2016;36:30–34.

    CAS  Article  Google Scholar 

  21. USDA ERS—Urban Influence Codes. https://www.ers.usda.gov/data-products/urban-influence-codes/. Accessed 15 Feb 2021.

  22. Interrante J, Carroll C, Handley S, Kozhimannil K. An enhanced method for identifying hospital-based obstetric unit status. 2021. https://3pea7g1qp8f3t9ooe3z3npx1-wpengine.netdna-ssl.com/wp-content/uploads/2022/01/UMN-OB-Unit-Identification-Methods_7.pdf.

  23. How does CDC identify severe maternal morbidity? | CDC. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/severe-morbidity-ICD.htm. Accessed 7 Sept 2021.

  24. California Maternal Quality Care Collaborative. NQF # 716: Unexpected newborn complications update (aka Healthy Term Newborn) summary of measure updates. March 2013.

  25. Interrante JD, Tuttle MS, Basile Ibrahim B, Admon LK, Kozhimannil KB. Policy brief: state and regional differences in access to hospital-based obstetric services for rural residents, 2018. https://3pea7g1qp8f3t9ooe3z3npx1-wpengine.netdna-ssl.com/wp-content/uploads/2021/09/UMN-State-Regional-Differences-in-OB_Policy-Brief_8.16.21_508.pdf. Accessed August 2021.

  26. Handley SC, Passarella M, Srinivas SK, Lorch SA. Identifying individual hospital levels of maternal care using administrative data. BMC Health Serv Res. 2021;21:1–11.

    Article  Google Scholar 

  27. Srinivas SK, Kozhimannil K, Hung P, Attanasio L, Jou J, Grobman WA. Do hospitals with a higher level of maternal care designation have better maternal outcomes? Am J Perinatol. 2019;36:653–8.

    Article  Google Scholar 

  28. Vanderlaan J, Rochat R, Williams B, Dunlop A, Shapiro SE. Maternal health associations between hospital maternal service level and delivery outcomes. Women’s Heal Issues. 2019;29:252–8.

    Article  Google Scholar 

  29. Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Major survey findings of listening to mothers III: pregnancy and birth. J Perinat Educ. 2014;23:9.

    Article  Google Scholar 

  30. Hansen AC, Slavova S, O’Brien JM. Rural residency as a risk factor for severe maternal morbidity. J Rural Health. 2022;38:161–70.

    Article  Google Scholar 

  31. Cameron NA, Molsberry R, Pierce JB, Perak AM, Grobman WA, Allen NB, et al. Pre-pregnancy hypertension among women in rural and urban areas of the United States. J Am Coll Cardiol. 2020;76:2611–9.

    Article  Google Scholar 

  32. 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. 2019;38:2077–85.

    Article  Google Scholar 

  33. Saint Onge JM, Smith S. Demographics in rural populations. Surg Clin N. Am. 2020;100:823–33.

    Article  Google Scholar 

  34. Probst J, Eberth JM, Crouch E. Structural urbanism contributes to poorer health outcomes for rural America. Health Aff. 2019;38:1976–84.

    Article  Google Scholar 

  35. Clapp MA, Srinivas SK, Kozhimannil KB, Grobman WA, Kaimal AJ. Comparison of maternal and neonatal subspecialty care provision by hospital. Am J Perinatol. 2021. https://doi.org/10.1055/s-0041-1727223

  36. Kozhimannil KB, Henning-Smith C. Improving health among rural residents in the US. JAMA 2021;325:1033–4.

    Article  Google Scholar 

  37. Howell EA, Janevic T, Hebert PL, Egorova NN, Balbierz A, Zeitlin J. Differences in morbidity and mortality rates in black, white, and hispanic very preterm infants among New York City Hospitals. JAMA Pediatr. 2018;172:269–77.

    Article  Google Scholar 

  38. Villar J, Ariff S, Gunier RB, Thiruvengadam R, Rauch S, Kholin A, et al. Maternal and neonatal morbidity and mortality among pregnant women with and without COVID-19 infection: the INTERCOVID multinational cohort study. JAMA Pediatr. 2021;175:817–26.

    Article  Google Scholar 

  39. Handley SC, Srinivas SK, Lorch SA. Regionalization of care and the maternal-infant dyad disconnect. JAMA. 2019;322:503–4.

    Article  Google Scholar 

  40. Brantley MD, Davis NL, Goodman DA, Callaghan WM, Barfield WD. Perinatal regionalization: a geospatial view of perinatal critical care, United States, 2010-2013. Am J Obstet Gynecol. 2017;216:185.e1–185.e10.

    Article  Google Scholar 

  41. DeSisto CL, Okoroh EM, Kroelinger CD, Barfield WD. Summary of neonatal and maternal transport and reimbursement policies—a 5-year update. J Perinatol. 2022. https://doi.org/10.1038/s41372-022-01389-3.

Download references

Author information

Authors and Affiliations

Authors

Contributions

SCH conceptualized and designed the study, interpreted the data, and drafted the manuscript. MP completed the data analysis, interpreted the data, and critically revised the manuscript. JDI interpreted the data and critically revised the manuscript. KBK participated in the design of the study, interpretation of the data, and critically revised the manuscript. SAL contributed to study conceptualization, interpretation of the data, and critically revised the manuscript.

Corresponding author

Correspondence to Sara C. Handley.

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.

Rights and permissions

Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Handley, S.C., Passarella, M., Interrante, J.D. et al. Perinatal outcomes for rural obstetric patients and neonates in rural-located and metropolitan-located hospitals. J Perinatol (2022). https://doi.org/10.1038/s41372-022-01490-7

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1038/s41372-022-01490-7

Search

Quick links