Purpose

The goal of this study was to evaluate how rural/urban status and other risk factors alter women's odds of severe maternal morbidity (SMM) at delivery.

Methods

This study used 48,608 Kentucky resident delivery hospitalization records from 2017. We used multiple logistic regression with interaction terms to evaluate the moderating effect of rural/urban residence with other risk factors. We reported adjusted odds ratios (aORs) and 95% confidence intervals (CIs) as measures for association with the outcome of SMM at delivery.

Findings

The percentage of delivery hospitalizations with SMM was higher for women with rural (2.4%) versus metro (1.1%) or metro-adjacent (1.5%) residence (p < .001). Rural status moderated the effect of anemia on SMM. The aOR for SMM for women with anemia versus those without was 8.56 (CI: 4.89–14.97) in rural areas, two times higher than in metro areas (aOR 3.87; CI: 3.09–4.86). Kentucky Appalachian region (aOR 1.90; CI: 1.46–2.47), Black race (aOR 1.30; CI: 1.02–1.66), history of cesarean section (aOR 1.28; CI: 1.07–1.52), hypertension (aOR 10.55; CI: 5.67–19.62), and opioid use (aOR 1.72; CI: 1.19–2.47) were significantly associated with SMM.

Conclusion

Rural women in Kentucky are at an increased risk for SMM. Quality and safety programming should specifically address the needs of isolated subpopulations. Women living in rural areas are more likely to experience SMM given an anemia diagnosis. The underlying cause and clinical management of anemia may differ between rural and urban areas.