Rural-urban differences in obstetric care trends, 2002-2010

Background: Approximately one-quarter of all U.S. births occur in rural hospitals. Regionalization and hospital closures have affected obstetric practice in rural vs. urban settings, and this is happening alongside major shifts in obstetric care nationally. This analysis measured changes in obstetric care quality in rural and urban hospitals over the past decade.

Methods: Using 2002-2010 data from the Nationwide Inpatient Sample (NIS), an approximate 20% sample of US hospitals, we identified all obstetric deliveries (N=7,188,972 total; 6,316,743 births in urban hospitals and 837,772 births in rural hospitals). We used generalized estimating equations to assess differences between rural and urban hospitals in cesarean delivery among lower risk mothers, vaginal birth after cesarean (VBAC), non-indicated cesarean delivery, non-indicated labor induction, episiotomy, and perineal laceration.

Results: In 2010, over 30% of lower-risk women delivered babies via cesarean, and 13% of cesarean deliveries were performed without definitive medical indication in both rural and urban hospitals. Between 2002 and 2010, cesarean delivery among lower risk women was more common in rural hospitals (AOR=1.61, p<0.001) and increased more rapidly in rural hospitals, compared with urban hospitals (annual AOR=1.04, p<0.001), after controlling for demographic factors and health insurance coverage. Labor induction without medical indication was less common in rural vs. urban hospitals (AOR=0.89, p<0.001) but increased more rapidly in rural hospitals between 2002 and 2010 (annual AOR=1.05, p<0.001).

Conclusions: Our findings indicate that some concerning maternity care trends (increases in low-risk cesarean and non-indicated labor induction, for example) differentially impact deliveries in rural hospitals.