Washington, DC -- Lack of access to adequate women's health care puts rural women in the US at a greatly increased risk of poor health outcomes compared with women in urban areas. The physician shortage in rural areas, limited resources at small community hospitals, and patient factors such as lack of insurance or the need to travel long distances to receive care all contribute to major disparities that rural women face, according to a Committee Opinion released today by The American College of Obstetricians and Gynecologists (ACOG).
"Rural communities are home to 17% of all females 15 and older in the US, and 18% of all US births take place there," said Alan G. Waxman, MD, chair of ACOG's Committee on Health Care for Underserved Women. "Unfortunately, nearly one-third of rural women live in counties with no ob-gyn at all. Location is a serious health disadvantage for these women."
Rural women are more likely to have a cesarean delivery, low-birth-weight infant, and neonatal and postneonatal mortality and are less likely to be offered a vaginal birth after cesarean (VBAC). Teenagers in the rural South have the highest adolescent birth rate in the country. Racial and ethnic disparities in health care may also be amplified in rural settings. In rural hospitals, black women on Medicaid have been shown to be at greater risk of experiencing potentially avoidable maternity complications than white women on Medicaid.
"When compared with their urban counterparts, US rural women experience higher rates of cervical cancer, and they receive fewer preventive screenings such as mammograms, Pap tests, and colorectal screening. They are also less likely to have received at least one family planning service in the past year and have an increased risk of receiving inadequate, late, or no prenatal care," said Eliza Buyers, MD, a committee member who helped develop the document. "Without enough health care facilities and clinicians to provide basic women's health care, these women are at a higher risk of developing problems that could be prevented.
"Their reproductive health care is also in jeopardy," Dr. Buyers continued. "Many of the least-populated communities do not have publicly funded family planning clinics, severely limiting a woman's contraceptive options."
Attracting physicians to rural, sometimes remote, areas is a challenge for local communities. Numerous hospitals in rural and sparsely populated counties have closed their obstetric units due to low volume of deliveries, financial vulnerability from a high proportion of Medicaid patients, medical liability concerns, or difficulty finding staff, including ob-gyns, anesthesiologists, and family physicians, for the obstetric units.
Some states, university medical centers, and health agencies are making efforts to improve services to rural women. Oregon offers financial incentives such as an income tax credit and medical liability insurance assistance for obstetricians that practice in rural areas. Pregnant women and infants in Wyoming—a state with few pediatric specialists and tertiary care centers—can apply Medicaid benefits to out-of-state providers. The ob-gyn department at the University of Texas Medical Branch in Galveston runs a program that services geographically underserved women at 37 off-site clinics and provides transportation and electronic medical records to uphold continuity of care.
"It's encouraging to see the positive changes that are slowly happening, but we need more efforts like these in rural communities everywhere. Clearly, we have a lot more ground to cover," Dr. Waxman added.
The Committee Opinion suggests ways in which ob-gyns can help increase access to women's health services in nonurban areas:
- Collaborate with state maternal-child and rural health agencies to identify health needs of rural women and barriers to care. Join a task force or advisory committee focused on improving the health of rural women
- Reinvigorate the implementation of regionalized perinatal care in underserved, rural areas. Share network resources and clinical expertise
- Encourage and participate in efforts to utilize effective telemedicine technologies to expand and improve services for rural women
- Advocate for comprehensive medical liability reform to facilitate the practice of providers in rural areas
- Conduct further research to understand acceptable conditions for performance of VBAC and study the effect of VBAC delivery policies on access to care for rural women
- Advocate for increased access to contraceptive methods and emergency contraception
- Advocate for availability of safe, legal, and accessible abortion services
"Ob-gyns have the ability to help improve health care for rural women," Dr. Waxman said. "ACOG encourages ob-gyns to get involved in the process because every woman deserves to be cared for, no matter where she lives."
Committee Opinion #429 "Health Disparities for Rural Women" is published in the March 2009 edition of Obstetrics & Gynecology.