The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.
ABSTRACT: Significant health disparities exist for rural women in all categories of women's health, including obstetric and gynecologic outcomes and access to care. Minority women living in rural areas may face even greater risks based on their combined characteristics. Many rural areas have limited numbers of health care providers, particularly those who provide obstetric and gynecologic care. Generalizations regarding rural America are difficult because of the heterogeneity of rural areas within the United States and even within the borders of a single state. Health professionals are encouraged to engage in activities to diminish health disparities for rural women.
Significant health disparities exist between women living in rural and urban areas. For most people, the term "rural" implies regions that are less populated and geographically distant compared with urban areas. Multiple agencies, policy makers, and researchers have included aspects of these notions in the many definitions used to study and report population data, and to determine eligibility and reimbursement levels for numerous federal and state programs. Two commonly used definitions are those generated by the Office of Management and Budget and the U.S. Census Bureau, which characterize territories or populations as metropolitan/nonmetropolitan and urban/rural respectively (1–3).*# In this document, because of definitional complexities, the term "rural" will be used interchangeably with "nonmetropolitan" and the term "urban" will be used interchangeably with "metropolitan."
Rural America represents 80% of the national landmass and is home to 17% of U.S. females aged 15 years and older and approximately 18% of all live births per year (4–7). Rural communities are extremely heterogeneous, with substantial regional differences in ethnic and racial composition (8). Whereas 82% of nonmetropolitan residents are non-Hispanic white, Hispanics and Asians are now the fastest growing rural subgroups (4). Well-documented racial and ethnic health disparities (9) may be amplified by additional barriers to care in rural areas.
Rural Health Disparities
Although national data on women's health and outcomes according to residence are relatively sparse, disparities for rural women are apparent. Rates of rural women's health disparities presented as follows reflect comparisons with their urban counterparts unless otherwise noted. General health conditions and behaviors for which U.S. rural women experience higher rates include unintentional injury and motor vehicle related deaths, suicide, cigarette smoking, obesity, limitation of activities caused by chronic health conditions (8), and incidence of cervical cancer (10). Other comparisons show that the ischemic heart disease death rate in rural women exceeds that for all U.S. women, and in some regions of the country, there are higher rates of heavy alcohol consumption for women in nonmetropolitan areas (8). Proportionately fewer rural women receive such recommended preventive services as a recent mammogram, Pap test, or colorectal screening; however, when income and other sociodemographic variables are controlled, only the difference for obtaining a mammogram is significant (11).
Other examples of less favorable outcomes for U.S. rural women and their infants related to obstetric and gynecologic practice include lower likelihood of receiving at least one family planning service within the past year (5); highest adolescent birth rates in the nation for rural teenagers in the South (8); increased risk of inadequate prenatal care (including late or no prenatal care) that is especially apparent in rural counties nonadjacent to metropolitan counties (6); higher overall adjusted risk of low-birth weight that is significantly greater for residents of rural counties with at least 20% of their population living in poverty for three decades compared with residents of all other rural counties (6); and a 17.4% higher risk of neonatal mortality and a 19.3% higher risk of postneonatal mortality for rural infants after adjusting for maternal age, parity, race, marital status, education, and inadequate prenatal care (6). In rural hospitals, African-American Medicaid beneficiaries are at greater risk of potentially avoidable maternity complications than non-Hispanic white Medicaid beneficiaries, despite lower potentially avoidable maternity complications rates for all Medicaid deliveries in rural hospitals compared with urban hospitals (12).
Data in the 2001 Nationwide Inpatient Sample reveal differences in rates of cesarean delivery in rural hospitals. Although the total rate in rural hospitals was identical to that in urban nonteaching hospitals, small rural hospitals with an average daily census of less than 10, 25–49, or 100–249 had significantly higher cesarean delivery rates than comparable urban hospitals (13).
Health Services Access and Availability
Access to health care for rural residents is complicated by patient factors as well as those related to the delivery of care. Rural residents are more likely to be poor, lack health insurance, or rely substantially on Medicaid and Medicare; they also travel longer distances to receive care or to access a range of medical, dental, and mental health specialty services (1). Increasing closures of hospital-based obstetric services and decreasing percentages of all physicians doing deliveries, exacerbated by reluctance to select rural practice, is disquieting. In 2002, only 56% of women living in nonmetropolitan counties and 21% of women in counties with no population made up of 2,500 or more individuals per square mile had access to obstetric care in a local hospital. Reasons cited by hospital administrators for closing obstetric units include low volumes of deliveries, financial vulnerability because of Medicaid patients, malpractice burden, and difficulty finding staff for the obstetric unit (eg, obstetricians, anesthesiologists, family physicians) (14). Counties without an obstetrician–gynecologist affect 5.8 million (29%) rural women (7). In some rural areas, family physicians provide 100% of obstetric care. Data show that an increasing proportion of women are entering obstetrics and family practice; however, substantially fewer females compared with males in both specialties choose to practice in rural areas (15–17). This could contribute to a potential decrease in the rural workforce.
Obstetric and gynecologic health services along with family planning options are limited in some nonmetropolitan areas. Counties without publicly funded family planning clinics are typically the least populated (18). Data in the 2001 Nationwide Inpatient Sample reveal that the rate of vaginal birth after cesarean delivery in rural hospitals (17.8%) was statistically lower than that for urban nonteaching hospitals (20%) and for urban teaching hospitals (25.5%) (13). Local availability of abortion services is restricted. Ninety-seven percent of nonmetropolitan counties have no abortion provider. Nonhospital abortion providers estimate that 19% of their patients travel 50–100 miles, and 8% travel more than 100 miles (19). There also is concern about availability of emergency contraception. Data on current over-the-counter availability of emergency contraception in rural pharmacies are lacking.
Current Initiatives to Improve Services for Rural Women
Regional organization of perinatal services is an important strategy to improve outcomes for underserved women and their infants in rural communities, although implementation can be a challenge in these areas. One indicator used to measure how the system is functioning is the percentage of very low birth weight (less than 1,500 grams) deliveries that take place in subspecialty hospitals. Twelve of the 15 states ranked the lowest in the country on this indicator have relatively high proportions of rural populations (20, 21). Some studies examining very low birth weight deliveries suggest that residing in more distant areas from a subspecialty facility, as well as inadequate prenatal care, increases the likelihood of delivery in a lower level facility (22, 23).
A variety of initiatives have been established to address the difficulties in providing care to rural women. There are multiple sources of funding, such as a range of state programs (eg, Medicaid) and medical school department budgets. Examples of recent or current approaches are listed as follows:
- Oregon enacted legislation to offer financial incentives such as a state income tax credit for rural practitioners and assistance with medical liability insurance for obstetricians practicing in rural areas (24).
- The University of Missouri-Columbia Family Practice Residency Program incorporated a rural obstetric rotation to increase the practice of obstetrics among family physicians (25).
- Wyoming, a state with no tertiary care centers for pregnant women or infants and few pediatric specialists, approves out-of-state providers and facilities as state Medicaid providers. This allows the state to reimburse transport to and care and delivery in an out-of-state subspecialty hospital when medically necessary (26).
- The Department of Obstetrics and Gynecology at the University of Texas Medical Branch in Galveston developed its Regional Maternal & Child Health Program to serve geographically underserved women in 37 off-site clinics. The program addresses culturally relevant services and transportation needs, and uses an electronic medical record to facilitate continuity of care. It also provides free housing in its Regional Perinatal Residence for high-risk women (and family members) living in distant locations to facilitate their access to regional center care when hospitalization is not necessary (27).
- The Arkansas Medicaid Program and the University of Arkansas for Medical Sciences are collaborating with the state's medical community to enhance primary obstetric care in rural Arkansas and increase risk-appropriate referrals to maternal–fetal medicine subspecialists. Their system uses telemedicine and clinic networks to facilitate access to maternal–fetal medicine consultation services, and to provide continuing education for practitioners (28).
Obstetricians and gynecologists in every region of the United States can work to reduce rural health disparities. The diversity of rural communities necessitates local solutions to local problems. Suggestions are listed as follows:
- Collaborate with maternal-child and rural health agencies in your state to identify the health needs of rural women and barriers to care. Share your professional expertise as a member of an advisory committee or task force focused on improving the health of rural women.
- Partner with family physicians and other women's primary care providers to ensure that appropriate consultation and training are available for practitioners in rural areas.†
- Promote state initiatives offering financial incentives to rural practitioners and providers of rural obstetric care and reproductive health services.
- Reinvigorate the implementation of regionalized perinatal care in underserved, rural areas. Share and network resources as well as clinical expertise.
- Encourage and participate in efforts to utilize effective telemedicine technologies to expand and improve services for rural women.
- Advocate for comprehensive professional liability reform to facilitate the practice of providers in rural areas.
- Conduct further research to understand acceptable conditions for performance of vaginal birth after cesarean delivery in rural areas and to study the effect of vaginal birth after cesarean 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.
- Include place of residence in the collection of data for health-related databases and their analyses to ensure improved understanding of rural–urban health disparities among women.
- Rural health disparities are only partially due to lack of health care services. Rural communities have disparities in education, employment, and poverty that also should be addressed.
† For more information see, American Academy of Family Physicians, American College of Obstetricians and Gynecologists. AAFP-ACOG joint statement on cooperative practice and hospital privileges. ACOG Statement of Policy 73. Leawood (KS): AAFP; Washington, DC: ACOG; 1998.
- Hart LG, Larson EH, Lishner DM. Rural definitions for health policy and research. Am J Public Health 2005; 95:1149–55.
- Rural Policy Research Institute. Choosing rural definitions: implications for health policy. Rural Policy Research Institute Health Panel Issue Brief No. 2. Columbia (MO): RUPRI; 2007. Available at: http://www.rupri.org/Forms/RuralDefinitionsBrief.pdf. Retrieved August 25, 2008.
- Rural Assistance Center. What is rural? Grand Forks (ND): RAC; 2008. Available at: http://www.raconline.org/info_ guides/ruraldef. Retrieved August 25, 2008.
- United States Department of Agriculture Economic Resource Service. Rural population and migration. Washington, DC: USDA; 2007. Available at: http://ers.usda.gov/briefing/population. Retrieved August 25, 2008.
- Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of U.S. women: data from the 2002 National Survey of Family Growth. Vital Health Stat 23 2005;(25):1–160.
- University of Washington Rural Health Research Center. Poor birth outcome in the rural United States: 1985-1987 to 1995-1997. Final Report No. 119. Seattle (WA): UWRHRC; 2008. Available at: http://depts.washington.edu/uwrhrc/uploads/RHRC_FR119_Larson.pdf. Retrieved August 25, 2008.
- National Center for Health Statistics. Health, United States, 2007: with chartbook on trends in the health of Americans. Hyattsville (MD): NCHS; 2007. Available at: http://www.cdc.gov/nchs/data/hus/hus07.pdf. Retrieved August 25, 2008.
- National Center for Health Statistics. Health, United States, 2001: with urban and rural health chartbook. Hyattsville (MD): NCHS; 2001. Available at: http://www.cdc.gov/nchs/data/hus/hus01.pdf. Retrieved August 25, 2008.
- Racial and ethnic disparities in women's health. ACOG Committee Opinion No. 317. Obstet Gynecol 2005; 106:889–92.
- Benard VB, Coughlin SS, Thompson T, Richardson LC. Cervical cancer incidence in the United States by area of residence, 1998 2001. Obstet Gynecol 2007;110:681–6.
- Larson S, Correa-de-Araujo R. Preventive health examinations: a comparison along the rural-urban continuum. Womens Health Issues 2006;16:80–8.
- Laditka SB, Laditka JN, Bennett KJ, Probst JC. Delivery complications associated with prenatal care access for Medicaid-insured mothers in rural and urban hospitals. J Rural Health 2005;21:158–66.
- Greene SB, Holmes GM, Slifkin R, Freeman V, Howard HA. Cesarean section rates in rural hospitals. Findings Brief. Chapel Hill (NC): North Carolina Rural Health Research and Policy Analysis Center, Cecil G. Sheps Center for Health Services Research; 2005. Available at: http://www.shepscenter.unc.edu/research_programs/rural_program/FB79.pdf. Retrieved August 25, 2008.
- Zhao L. Why are fewer hospitals in the delivery business? NORC Walsh Center for Rural Health Analysis Working Paper #2007-04. Rockville (MD): Office of Rural Health Policy; 2007.
- American College of Obstetricians and Gynecologists. Profile of ob-gyn practice. Washington, DC: ACOG; 2004. Available at: http://www.acog.com/from_home/departments/practice/ProfileofOb-gynPractice1991-2003.pdf. Retrieved September 17, 2008.
- Emmons SL, Nichols M, Schulkin J, James KE, Cain JM. The influence of physician gender on practice satisfaction among obstetrician gynecologists. Am J Obstet Gynecol 2006;194:1728–38; discussion 1739.
- Colwill JM, Cultice JM. The future supply of family physicians: implications for rural America. Health Aff 2003;22:190–8.
- Frost JJ, Frohwirth L, Purcell A. The availability and use of publicly funded family planning clinics: U.S. trends, 1994–2001. Perspect Sex Reprod Health 2004;36:206–15.
- Jones RK, Zolna MR, Henshaw SK, Finer LB. Abortion in the United States: incidence and access to services, 2005. Perspect Sex Reprod Health 2008;40:6–16.
- Maternal and Child Health Bureau. Search TVIS national performance measures: most recent year available. Available at: https://perfdata.hrsa.gov/mchb/mchreports/Search/core/corsch01p.asp. Retrieved September 2, 2008.
- U.S. Census Bureau. Table A-2. States — population by residence. In: State and metropolitan area data book: 2006. Washington (DC): Census; 2006. p. 4. Available at: http://www.census.gov/prod/2006pubs/smadb/smadb-06tablea.pdf. Retrieved September 2, 2008.
- Samuelson JL, Buehler JW, Norris D, Sadek R. Maternal characteristics associated with place of delivery and neonatal mortality rates among very-low-birthweight infants, Georgia. Paediatr Perinat Epidemiol 2002;16:305–13.
- Gould JB, Sarnoff R, Liu H, Bell DR, Chavez G. Very low birth weight births at non-NICU hospitals: the role of sociodemographic, perinatal, and geographic factors. J Perinatol 1999;19:197–205.
- Oregon Office of Rural Health. Providers. Available at: http://www.ohsu.edu/ohsuedu/outreach/oregonruralhealth/providers/index.cfm. Retrieved September 2, 2008.
- Delzell JE Jr, Ringdahl EN. The University of Missouri Rural Obstetric Network: creating rural obstetric training sites for a university-based residency program. Fam Med 2003; 35:243–5.
- Maternal and Child Health Bureau. State narrative for Wyoming: application for 2008 annual report for 2006. Maternal and Child Health Services Title V Block Grant. Rockville (MD): MCHB; 2007. Available at: https://perfdata.hrsa.gov/mchb/mchreports/documents/2008/Narrative/WY-Narratives.pdf. Retrieved October 1, 2008.
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Health Disparities for Rural Women. ACOG Committee Opinion No.429. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:762–5.