Introduction

According to the 2010 US Census, nearly 20% of the US population resides in rural areas, including 28 million women of reproductive age.1 These populations experience health disparities stemming from social and structural determinants of health which perpetuate suboptimal health behaviors including educational, economic and workplace, social and community, and policy factors. In addition, health care services differ in rural facilities as compared with urban centers, which may exacerbate the risk for adverse events including preventable morbidity and mortality. This article will review characteristics of and population trends in rural America including health behaviors, health care access and quality of care, and finally maternal health outcomes experienced by rural residents. It is important to recognize the diversity within and between rural populations in the United States; the descriptions provided in this article are taken from population studies and largely center on the contextual factors within rural areas that may drive population-level health disparities. The authors recognize and celebrate the diversity and vitality of rural life. The data presented are not meant to create or perpetuate stereotypes about rural individuals.

DEFINING RURAL

There are several classification systems used to define rurality or urbanicity based on population density or distance from urban centers. The US Census Bureau identifies territories of census tracts and/or census blocks with high population density as urbanized areas (50,000 or more people) and urban clusters (at least 2500 and less than 50,000 people).1 All populations and territories not within an urban area or urban cluster are considered rural. By US Census Bureau definition, 19.3% of the total US population was classified as rural in 2010. The Federal Office of Management and Budget (OMB) defines metropolitan and micropolitan core-based statistical areas (CBSAs) at the county or county equivalent level based on the US Census Bureau population estimates.2 Each CBSA consists of 1 or more entire counties containing an urban core and the adjacent counties with economic integration, measured by commuting, with the urban core. Metropolitan CBSAs have a population of 50,000 or more and micropolitan CBSAs have a population of at least 10,000 or more but less than 50,000. Areas outside these CBSAs are considered rural. By the OMB CBSA definition, ∼84% of the US population is metropolitan, 10% is micropolitan, and only 6% is considered rural. Finally, the National Center for Health Statistics (NCHS) utilizes a 6-level urban-rural classification scheme. The NCHS classification is at the county or county equivalent level and is most similar to the OMB standard, however, has more levels (4) for metropolitan areas to offer further delineation within this large portion of the US population. Table 1 provides a comparison of these commonly used classification systems. Figure 1 provides a map of the US showing the NCHS county classification. Several other definitions of rural are used by various federal agencies including the Federal Office of Rural Health Policy, classification of frontier and remote areas within rural areas, and rural-urban commuting areas (RUCAs) defined by commuting patterns at the census tract level. It is important when considering data on rural populations to understand how the authors have defined rurality, when possible.

TABLE 1 - Common Classification Schemes for Place of Residence Used by Federal Agencies Agency US Census Bureau* Urban Area Urban Cluster Rural  Definition 50,000 or more people At least 2500 and less than 50,000 people <2500 people  Portion of the population (2010) 71.2% 9.5% 19.3% Office of Management and Budget (OMB)* Metropolitan Statistical Areas (MSAs) Micropolitan Rural  Definition 50,000 or more people At least 10,000 and less than 50,000 people <10,000 people  Portion of the population (2010) 84% 10% 6% National Center for Health Statistics (NCHS)†  Geographic area Metropolitan Micropolitan Noncore (rural) Large central metro Large fringe metro Medium metro Small metro  Definition MSA of 1 million or greater containing entire principal city or at least 250,000 residents of principal city MSA of 1 million or greater that do not quality as large central metro MSA of 250,000–999,999 MSA <250,000 Micropolitan counties in micropolitan statistical areas Noncore counties not in micropolitan statistical areas  Portion of the population (2013) 30.5% 24.7% 20.9% 9.2% 8.7% 6.1%
FIGURE 1: Characteristics of Rural Populations

Rural populations have unique demographics and recognized health disparities broadly including a greater prevalence of chronic disease and premature death than the overall US population. Some of these disparities may stem from differing health-related behaviors practiced by rural residents as compared with those residing in metropolitan and micropolitan areas. Other social and structural factors influencing the health of a population are explored including educational and economic factors.

DEMOGRAPHIC TRENDS

The overall US rural population is shrinking and aging as compared with urban populations, with a greater proportion of the population aged 55 and older. Out-migration of young people and in-migration of retirees both contribute to the older population distribution in rural areas. The lower portion of the population being of reproductive age also suggests less opportunity for population growth through childbirth. Out-migration of young adults raised in rural areas may be compensated in some areas by higher fertility rates among rural women who tend to bear more children than urban women. There is significant geographic variation in rural population trends with urban-adjacent areas experiencing growth of destination communities and more remote rural areas seeing significant population loss.4 Loss of rural population has significant implications for local economies including health care facilities, which are often one of the largest employers in small communities.

Although rural areas are, generally, less diverse than urban areas, the racial and ethnic diversity within and between rural areas is growing. Racial and ethnic minority populations grew in rural areas by ∼20% between 2000 and 2010, whereas the population of non-Hispanic whites in rural areas was unchanged.5 Specifically, rural Hispanic populations grew significantly, accounting for over half of population growth in rural areas during this time. However, Hispanic population growth is not evenly distributed across all rural areas. Population growth is occurring in areas seeing an increase in agricultural and other manufacturing opportunities, creating new destination communities for Hispanic and other immigrant families. Population growth is likely due to both migration and childbirth. The relatively young age of new Hispanic residents limits population loss due to death.

EDUCATION

The relationship between educational achievement, economic opportunities, and health is well established.6–8 What is not always considered is the portion of Americans who experience poverty who reside in rural and micropolitan communities and the structural challenges these individuals may face against upward social mobility. Childhood poverty rates are similar between rural and urban areas at ∼20%. Household income influences early educational achievement, which impacts the educational trajectory for the individual. However, the economic disadvantage may impact educational development in different ways in rural areas as there may be fewer community resources to mitigate the effects of poverty, such as after-school programs and centers for low-income youth. This theory is supported by evidence showing that across the rural-urban continuum, the relationship between household income and early academic skills differs, with a small increase in income associating with a greater improvement within urban communities.9 Thus, a large increase in household income is required for low-income rural children to experience the same degree of improvement in early academic skills as experienced with a more modest increase in income for urban children.

However, household income does not have to dictate early academic achievement. High-quality childcare and early childhood education have been shown to moderate the association between income and early educational achievement. Low income is less strongly predictive of underachievement for children who receive high-quality childcare, likely due to the promotion of early school readiness skills.10 However, rural children may have fewer opportunities to experience high-quality early childhood educational programs due to lower population density leading to fewer childcare centers and less choice for parents.

Differences in early childhood education are not the only educational differences between rural and urban areas. Although the achievement of a high school degree or equivalent is similar between rural and urban areas at 15%, only 19% of rural residents have a college education as compared with 33% of urban residents.11 Some of these differences may relate to the out-migration of higher academically achieving rural residents into urban areas in response to employment opportunities. There are also racial disparities in educational achievement in rural areas with 24% of non-Hispanic black and 39% of Hispanic residents in rural areas having a high school education.11

ECONOMIC OPPORTUNITIES AND EMPLOYMENT

Rural communities have long faced economic circumstances resulting in lower incomes. Although the overall poverty rate in the United States has declined in the past few decades, this has largely been driven by a decline in urban poverty as poverty rates have simultaneously increased in rural areas. After the conclusion of the economic recession in 2009, personal income was higher and grew significantly faster in metropolitan counties as compared with nonmetropolitan (rural and micropolitan) counties. Driving factors for this include the decline in farming and mining income in rural areas. The only job sector that has experienced significant growth over the past decade in nonmetropolitan areas is recreation.12 Population loss likely exacerbates the slow rate of employment growth experienced in rural areas.

Employment opportunities are shifting the population within rural communities. Loss of farming and mining jobs but the growth of other agricultural and industrial employment opportunities in rural areas impacts the economic potential of rural residents. The jobs tend to be low-wage and without significant opportunities for advancement. Rural manufacturing job opportunities are driving the migration of Hispanic and racial minority immigrants to rural areas. These sources of employment have implications on population health beyond household income. Manufacturing and other rural workers are exposed to greater rates of occupational injury.4 As a result, rural residents have a 35% greater nonfatal injury hospitalization rate as compared with urban residents. Not all injuries are occupational and rural residents also experience a greater risk for motor vehicle crashes and injury.4

HEALTH BEHAVIORS AND PREVENTATIVE HEALTH CARE

Data on health-related behaviors, chronic diseases and conditions, access to health care, and use of preventative health services are collected in an ongoing basis by The Behavioral Risk Factor Surveillance System (BRFSS). BRFSS is a telephone survey conducted by random digit dialing of landline and cellular phones. The 2013 BRFSS responses were evaluated for rural-urban differences, using the NCHS classification scheme for counties, for 5 health behaviors including sufficient sleep, current nonsmoking, nondrinking or moderate drinking, maintaining normal body weight, and meeting aerobic leisure time physical activity recommendations. The authors found that compared with adults living in 1 of the 4 types of metropolitan counties, adults who reside in micropolitan and noncore (rural) counties had a higher prevalence of nondrinking or moderate drinking, the similar prevalence of sufficient sleep, but a lower prevalence of the other 3 health behaviors, current nonsmoking, maintenance of normal body weight, and meeting aerobic leisure time activity.13

Other health-related evaluations based on rurality reveal differences in preventative care that likely contribute to health behavior disparities experienced by rural populations. Rural women are observed to receive preventative health interventions less frequently. Measures of preventative counseling as defined by the US Preventative Services Task Force recommendations were evaluated for Pennsylvania women of reproductive age based on rurality, as defined by rural-urban commuting areas codes. Women residing in rural areas were significantly less likely to receive counseling related to alcohol or drug use, tobacco use, birth control, nutrition, and physical activity. In their modeling, the authors observed that younger age, higher educational achievement, and seeing an obstetrician-gynecologist were associated with greater receipt of preventative counseling.14 Pregnant women residing in rural areas were also less likely to receive an annual influenza vaccination or have this recommended by their health care provider, after adjusting for other population differences.15 These findings suggest a need to consider health care system access challenges and quality of preventative health care services within micropolitan and rural counties to optimize health behaviors and the state of health before pregnancy that have downstream impacts on pregnancy outcomes.

HEALTH LITERACY

Health literacy refers to an individual’s capacity to use knowledge and critical thinking to drive appropriate access of health care services to manage their health and the health of those they care for. Health literacy also intersects with cultural values and norms around health care. The growth of the rural Hispanic and racial minority immigrant populations contributes to growing challenges with reduced health literacy and cultural congruence in rural areas. Reduced health literacy can compound with other structural barriers to health care including shortage of specialty care providers, geographic distance, and cultural incongruence with urban medical centers experienced by rural residents with chronic medical conditions, offering insight into drivers of disparate health outcomes.16 However, low health literacy does not have to be a stagnant barrier to improved outcomes. Engagement with the Healthy Start Program has been shown to advance health literacy among low-income rural pregnant women, suggesting that care connectivity and continuity provided by case managers is one strategy to improve health literacy and pregnancy outcomes.17

Structural Challenges to Maternity Care in Rural Areas

Rural health care facilities and providers face unique economic challenges in the maintenance of services. Medicaid is the primary insurance payor in rural areas, covering over half of rural residents.18 Low revenues due to volume and payor mix coupled with fixed overhead costs, need for staff to maintain skills, and challenges of maintaining providers present significant challenges for some rural facilities to maintain obstetrical services. The financial demands are further strained by limited access to social services such as childcare, housing support, employment services, and transportation options. Acknowledging these barriers and considering alternative payment structures for low volume, rural providers may provide financial stability that is currently lacking for many facilities.

RURAL FACILITY CLOSURES

Many studies have investigated the rate and impact of declining numbers of rural health care facilities in recent years. The University of North Carolina Rural Health Research Program has maintained a tracking system of rural hospital closures since 2005, with the observation of 43 closures between 2005 and 2010 and 138 closures since 2010.19 Although hospital closures play an important role in decreasing access to care, they are matched by obstetric unit closures in hospitals that remain open. In 2014, experts at the University of Minnesota Rural Health Research Center reported an increase in rural US counties without hospital obstetric services from 46% to 55%.20 Between 2014 and 2018, the same group reported that 2.7% (n=53) of rural counties in the United States lost hospital-based obstetric services—suggesting a sustained decline in the past decade.21 Of these closures, most were not urban-adjacent. The consequence of hospital closures and service reductions is a steadily increasing distance required to obtain obstetric care. Less than half of women in rural communities have access to prenatal and delivery services within a 30-mile drive of their home and over 10% will drive more than 100 miles for these services.22 Women with Medicaid or no insurance live farther from obstetric facilities than women with private insurance, correlating with lower median household incomes and lower rates of college degree attainment.23

OBSTETRICAL WORKFORCE

Obstetrical workforce challenges impact access to obstetrical services including prenatal care and hospital-based labor and delivery services. As of 2008, only 6.4% of obstetrician-gynecologists (ob-gyns) practice in rural areas.24 The ratio of ob-gyns per 10,000 women between states and regions across, with rural states having the lowest density of ob-gyns. Within all states the density of ob-gyns is greatest in metropolitan areas, followed by micropolitan and rural. Approximately half of US counties have no ob-gyns in practice.25 These workforce trends present concerns about ongoing decline in obstetrical care availability for rural women, which is likely to perpetuate disparities in outcomes.

Ob-gyns are not the only providers capable of offering high-quality obstetrical care. Rural hospitals have higher rates of family medicine physicians, general surgeons, and shared nursing staff attending births, and over 30% of rural deliveries are attended by midwives as compared with only 10% overall in the United States26 Unfortunately, the portion of family physicians who provide obstetrical care is also declining, indicating a need for concerted effort whether family physicians are to remain the cornerstone of obstetrical care in rural areas.27

QUALITY OF CARE

The relationship between delivery volume and care quality has been explored to understand whether there is a minimum threshold for annual deliveries below which it is too challenging for a facility to maintain safe care. Between 2010 and 2018, 7% of births occurred in hospitals with 10 to 500 births/year and 12.3% occurred in hospitals with 500 to 1000 births/year, representing the lowest volume facilities.28 More than 60% of all hospitals providing obstetric services in the United States performed fewer than 3 deliveries per day.29 In all, 18.9% of these low-volume hospitals (<500 annual births) were located more than 30 miles from another obstetric hospital and only 23.9% were within 30 miles of a high-volume hospital, illustrating the challenges at the intersection of volume and geography.28

Unfortunately, concerns about the maintenance of care quality can impact rural facility closures, but low volume does not necessarily imply lower quality. Critical access hospitals, which are designated by the Centers for Medicare and Medicaid Services to decrease the financial vulnerability of rural facilities, have been shown to perform similarly to more urban institutions on outcomes such as cesarean delivery rates in low-risk women, cesarean delivery rates without medical indication, and episiotomy rates; however, they performed worse on obstetric complications, such as third and fourth degree lacerations than both urban and other rural facilities.30 Variations in outcomes may be attributable to fewer supportive services within the smallest hospital systems and/or a low annual delivery volume of individual obstetric providers.31

Obstetrical Outcomes for Rural Residents

Pregnancy outcomes including rates of morbidity and mortality and infant outcomes are critical to assess to understand the quality and safety of obstetrical health care available to rural residents.

MATERNAL MORTALITY

The Centers for Disease Control and Prevention (CDC) defines maternal mortality as a death of women whereas pregnant or within 42 days of termination of pregnancy, excluding accidental or incidental causes. This definition is also used by the National Institute of Health and the World Health Organization. The 2003 update to the US standard death certificate includes an indication of whether the individual was pregnant at the time of death or within the year before death. However, adoption of this update has been gradual and in postpartum cases, the provider may not reliably know this information. The Pregnancy Mortality Surveillance System (PMSS) within the CDC, defines pregnancy-related deaths as those occurring during pregnancy or within 1 year of the end of pregnancy from any cause related to or aggravated by the pregnancy. In general, this Pregnancy Mortality Surveillance System definition is used by maternal mortality review boards across the country, which are multidisciplinary committees in states and cities who review deaths among women with the aim to inform recommendations for preventing future deaths.

The US is recognized for its high rate of maternal deaths among other industrialized nations, despite high health care expenditures. In 2016, the pregnancy-related mortality ratio (PRMR) was 16.9 deaths per 100,000 live births.32 There are numerous disparities identified in PRMR between social groups in the US, including by geography. Rural residents are observed to experience 29.4 deaths per 100,000 live births as compared with 18.2 per 100,000 live births among urban residents.33 These deaths are more common in the postpartum period than during pregnancy or delivery and over one-third of deaths are related to cardiovascular conditions. Racial and ethnic minorities are at an even greater risk with mortality rates as high as 47.2 deaths per 100,000 live births among black mothers compared with 18.1 for non-Hispanic white mothers.32 This shocking difference conveys a 3 to 4-fold higher risk of dying or suffering serious illness from pregnancy-related causes regardless of socioeconomic status.34 These poor outcomes are echoed in other minority populations such as American Indian and Alaska native women, who experience twice the mortality rate of white women.32 These concerning disparities amplify when considering outcomes for racial and ethnic minority populations residing in rural areas, such as rural Hispanic communities and Native American and Native Alaskan women.

SEVERE MATERNAL MORBIDITY

The CDC defines severe maternal morbidity (SMM) as the unexpected outcomes of labor and delivery that cause short or long-term consequences to a woman’s health. These cases are identified using International Classification of Disease diagnosis and procedure codes for conditions such as organ failure, eclampsia, and sepsis. Rates of SMM events have been on the rise as the CDC first began reporting these outcomes, driven mostly by significant increases in rates of blood transfusion at the time of childbirth, but nontransfusion SMM events are also increasing. SMM events were 9% more common in rural women compared with their urban counterparts, even after adjustment for sociodemographic factors and underlying clinical conditions.35 This finding is concerning as it suggests that some cases of SMM experienced by rural residents may have been preventable whether more resources were available in the delivery facility or they had delivered at a facility with a higher level of care.

PRENATAL CARE

Receipt of prenatal care is an important strategy to improve pregnancy outcomes, particularly low birth weight, preterm birth, and stillbirth,36–38 however, nearly 1 in 4 pregnant women in the United States do not receive adequate prenatal care.39 Measures of prenatal care adequacy incorporate the trimester of prenatal care initiation, number of prenatal visits, and adjust for gestational age at delivery.39 Rural residents generally have to travel further to obtain various health care services, including prenatal care, which can impact the utilization of preventative health care.40 Disparities in prenatal care utilization generally follow those described for pregnancy outcomes with nonmetropolitan residence, lower income, lower educational achievement, and lack of insurance all associating with inadequate prenatal care achievement.41

In addition to measuring the quantity of prenatal care, it is important to consider the quality of care. A recent investigation into receipt of whether prenatal care within a commercially insured population was provided consistent with national guidelines defined 8 specific services in alignment with guidelines from the American College of Obstetricians and Gynecologists, the Centers for Disease Control and Prevention, the US Preventative Services Task Force, and/or the International Society of Ultrasound in Obstetrics and Gynecology. These services included testing for sexually transmitted infections, routine obstetrical laboratory panels, urine culture, urinalysis, ultrasound for anatomy assessment, oral glucose tolerance test, vaccination for tetanus, diptheria, and pertussis, and screening for Group B Streptococcus. Receipt of at least 6 of 8 services was used to define high-quality care. Overall, receipt of high-quality care did not improve with an increased number of prenatal visits, challenging the historical use of prenatal care adequacy indices and presenting an opportunity to consider value-based measures of care. However, significant disparities in care quality were observed across maternal age, race, income, and education. Rural residents were less likely to have high-quality care as compared with residents of urban-adjacent and urban areas.42

INFANT OUTCOMES

Infant outcomes including preterm birth rates and rates of low birth weight are also important obstetrical outcomes to consider for rural residents. It has been observed that rural counties that experienced the greatest number of hospital and obstetric unit closures also saw an increase in preterm birth rates, particularly in nonurban adjacent counties. Specifically, researchers at the University of Minnesota School of Public Health identified a 0.40-percentage point increase in preterm birth rates in the year after obstetric service loss from a baseline rate of 11.6% in these counties.43 The relationship between increased prematurity rates and inadequate access to care after the loss of obstetric units can be appreciated even after adjusting for race/ethnicity, education, and overall health conditions at the county level.44

Nonurban adjacent counties also saw higher rates of infants with low Apgar scores after obstetrical unit closures, and in the most remote areas across the country, the rate of low birth weight and infant mortality were higher compared with urban communities.45 In rural Alabama, between 2003 and 2017, counties without obstetric facilities experienced an infant mortality rate of 9.23 deaths per 1000 live births compared with 7.89 deaths in counties with a labor and delivery unit (P=0.0011).46 Multiple studies have found improved neonatal survival of very low birth weight infants when delivered at hospitals with high-level neonatal units. Lack of access to resources and care providers during the initial resuscitation after delivery has demonstrated a 30% to 75% increase in mortality for infants with a birth weight under 1500 grams born in lower volume hospitals.47 The decline in NICU services parallels the decline in access to obstetric services in rural settings over the past several decades.

PERINATAL MENTAL HEALTH

Perinatal mood disorders, including postpartum depression (PPD) and anxiety, are among the most common complications of pregnancy and childbirth48 and are experienced at a greater rate by rural residents than their urban counterparts.49 Despite highly effective treatments for depression, such as Cognitive Behavioral Therapy and Interpersonal Psychotherapy, most postpartum people with depression do not receive treatment.50 Barriers to receiving mental health care include beliefs that medical health professionals are not appropriate sources for emotional care, that depressed mood is not a legitimate illness, or that depressive symptoms are normal during the postnatal period.51 Those rural residents who do desire mental health care face additional challenges including a shortage of providers as well as heightened stigma around mental health conditions.52

Rural-urban differences in perinatal depression reflect underlying community differences. Greater odds of perinatal depression have been observed among rural women, after adjusting for differences in race, ethnicity, and maternal age.49 However, these differences became nonsignificant once education, insurance status, and WIC status were accounted for, demonstrating the important impact of socioeconomic factors on mental health.49 Although rurality itself does not seem to be a risk factor for PPD, due to socioeconomic differences in rural communities the prevalence of PPD is greater in rural areas. Rural individuals do face more barriers to accessing mental health care. Most rural areas in the US are designated as mental health professional shortage areas.53 Rural residents may also face greater stigma around seeking care for mental health conditions, a barrier that may be felt more acutely in rural communities where there are more social connections among community members and less anonymity.52 Telehealth, including tele-mental health, may be acceptable and practical options for some rural women experiencing perinatal mood disorders.

Preferences of Rural Patients

Patient preferences for pregnancy and postpartum care do not always align with current care standards. A recent survey revealed that most women prefer fewer prenatal care visits (10) than is recommended (12 to 14), more communication with health care providers between visits, and comfort with home monitoring of vital signs including weight, blood pressure, and fetal heart rate. Women also desired more postpartum visits, including 2 within the first 3 weeks after delivery.54 Given the geographic challenges faced by some rural women to access prenatal care, is plausible that their preference for fewer scheduled visits and more home monitoring and virtual-based care would be greater.

However, despite evidence supporting the safety of local and even out-of-hospital birth for low-risk rural women, rural residents have been observed to bypass local facilities to deliver and hospitals with higher volume and increased services without a clear medical need to do so.55,56 Bypassing behavior is more common among women with greater resources, such as those with private insurance, in most studies but also occurs for women who are insured with Medicaid.55 Contemporary estimates indicate as many as 25% of rural women may deliver at a nonlocal hospital. Some of this is driven by medical indication, such as preterm birth, multifetal gestation, and maternal conditions requiring a higher level of care. However, after controlling for these clinical factors, many rural women delivered in nonlocal facilities suggesting other factors influenced this decision such as women’s perceptions of local care.57 This phenomenon is not unique to obstetrical care with bypassing behaviors observed among rural nonelderly Medicare beneficiaries as well.58,59

There is little published literature to offer insight into the drivers of elective local hospital bypass within the US Studies from other high-income Western countries may offer insight but should be interpreted with some caution due to differences in health care systems and cultural norms for childbirth. Women in rural northern Scotland were evaluated for their birthing preferences, revealing a preference to travel further for consultant-led care (physician care) over local midwifery care. The reasons cited included the ability to manage any complications that could arise and overall feeling safer in facilities with more resources.60 A systematic review from the United Kingdom, where births are largely attended by midwives and various birth settings are available to low-risk women, noted that a substantial portion preferred a hospital-based setting where medical staff are available if needed in an emergency.61 These studies suggest that low-risk women from rural areas may be bypassing local facilities due to perceptions of increased safety for themselves and their baby if they deliver in facilities with greater resources to manage unexpected complications of childbirth. Health care providers caring for these women prenatally should engage in open dialog about risk assessments, patient preferences, and concerns around childbirth. Supporting low-risk women to deliver in their community would mitigate some of the challenges of low-volume on rural maternity units as well as ease burdens on rural women related to travel for care.

Conclusions

The richness of small community connections and empowerment of sustainable independent living are woven together into the fabric of rural American life. Despite its beauty, this way of life is tested daily by the limitations in resource allocations to small communities. Reproductive-age women are acutely aware of these limitations and regularly travel long distances for many services, including for obstetrical health care. Unfortunately, the impacts of social and structural health determinants coupled with challenges in accessing both health care for low-risk pregnancies as well as specialty care for high-risk women appears to impart increased risk for significant pregnancy complications and maternal death for this population. Although by some indicators low-volume rural facilities perform equally well for obstetrics, disparities in SMM and mortality suggest that there is a need to consider ways to improve health care delivery and quality in rural communities. The recent growth of telemedicine services, attention to standardized approaches to obstetrical emergencies, and the use of simulation-based educational programs are all promising solutions to maintain and strengthen rural obstetrical care.

References 1. U.S. Census Bureau. 2010 Census Urban and Rural Classification and Urban Area Criteria. Secondary 2010 Census Urban and Rural Classification and Urban Area Criteria October 8, 2021. 2021. Available at: https://www.census.gov/programs-surveys/geography/guidance/geo-areas/urban-rural/2010-urban-rural.html. Accessed May 18, 2022. 2. Wilson SG, Plane DA, Mackun PJ, et al. 2010 Census Special Reports, Patterns of Metropolitan and Micropolitan Population Change: 2000 to 2010. Secondary 2010 Census Special Reports, Patterns of Metropolitan and Micropolitan Population Change: 2000 to 2010. 2012. Available at: https://www.census.gov/library/publications/2012/dec/c2010sr-01.html. Accessed May 20, 2022. 3. Ingram DD, Franco SJ. 2013 NCHS urban–rural classification scheme for counties. National Center for Health Statistics. Vital Health Stat 2. 2014;166:8–11. 4. Saint Onge JM, Smith S. Demographics in rural populations. Surg Clin North Am. 2020;100:823–833. 5. Lichter DT. Immigration and the new racial diversity in rural America. Rural Sociol. 2012;77:3–35. 6. Lee H, Singh GK. Contributions of socioeconomic, demographic, and behavioral risk factors to all-cause mortality disparities by psychological distress in the united states: a blinder-oaxaca decomposition analysis of longitudinal data. Int J MCH AIDS. 2022;11:e533. 7. Zhao X, Xiao J, Chen H, et al. Patient preferences and attitudes towards first choice medical services in Shenzhen, China: a cross-sectional study. BMJ Open. 2022;12:e057280. 8. Suglia SF, Saelee R, Guzman IA, et al. Child socioeconomic status, childhood adversity and adult socioeconomic status in a nationally representative sample of young adults. SSM Popul Health. 2022;18:101094. 9. Miller P, Votruba-Drzal E, Setodji CM. Family income and early achievement across the urban-rural continuum. Dev Psychol. 2013;49:1452–1465. 10. Dearing E, McCartney K, Taylor BA. Does higher quality early child care promote low-income children’s math and reading achievement in middle childhood? Child Dev. 2009;80:1329–1349. 11. Marre A. Rural education at a glance. United States Department of Agriculture Economics Research Service. 2017. 12. Pender JHT, Cromartie J, Farrigan T. Rural America at a glance. United States Department of Agriculture Economics Research Service. 2019. 13. Matthews KA, Croft JB, Liu Y, et al. Health-related behaviors by urban-rural county classification—United States, 2013. MMWR Surveill Summ. 2017;66:1–8. 14. McCall-Hosenfeld JS, Weisman CS. Receipt of preventive counseling among reproductive-aged women in rural and urban communities. Rural Remote Health. 2011;11:1617. 15. Kaur R, Callaghan T, Regan AK. Disparities in maternal influenza immunization among women in rural and urban areas of the United States. Prev Med. 2021;147:106531. 16. Brundisini F, Giacomini M, DeJean D, et al. Chronic disease patients’ experiences with accessing health care in rural and remote areas: a systematic review and qualitative meta-synthesis. Ont Health Technol Assess Ser. 2013;13:1–33. 17. Mobley SC, Thomas SD, Sutherland DE, et al. Maternal health literacy progression among rural perinatal women. Matern Child Health J. 2014;18:1881–1892. 18. Medicaid and CHIP Payment and Access Commission. Issue Brief: Medicaid and rural health. 2021. Available at: https://www.macpac.gov/wp-content/uploads/2021/04/Medicaid-and-Rural-Health.pdf. Accessed May 21, 2022. 19. NC Rural Health Research Program. 181 Rural Hospital Closures since January 2005. Secondary 181 Rural Hospital Closures since January 2005. 2014. Available at: https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/. Accessed April 16, 2022. 20. Hung P, Henning-Smith CE, Casey MM, et al. Access to obstetric services In rural counties still declining, with 9 percent losing Services, 2004-14. Health Aff. 2017;36:1663–1671. 21. Kozhimannil KB, Interrante JD, Tuttle MKS, et al. Changes in hospital-based obstetric services in rural US counties, 2014-2018. JAMA. 2020;324:197–199. 22. ACOG Committee on Health Care for Underserved Women. ACOG Committee Opinion No. 586: health disparities in rural women. Obstet Gynecol. 2014;123(t 1):384–388. 23. Hung P, Casey MM, Kozhimannil KB, et al. Rural-urban differences in access to hospital obstetric and neonatal care: how far is the closest one. J Perinatol. 2018;38:645–652. 24. American College of Obstetrics and Gynecology. 2008 socioeconomic survey of ACOG fellows. Secondary 2008 socioeconomic survey of ACOG fellows 2008. Available at: http://www.acog.org/About_ACOG/ACOG_Departments/Practice_Management_and_Managed_Care/2008_Socioeconomic_Survey_of_ACOG_Fellows. Accessed May 18, 2022. 25. Health Resources and Services Administration. Area Health Resource Files. Available at: https://data.hrsa.gov/topics/health-workforce/ahrf. Accessed May 21, 2022. 26. Kozhimannil KB, Casey MM, Hung P, et al. The Rural Obstetric Workforce in US Hospitals: Challenges and Opportunities. J Rural Health. 2015;31:365–372. 27. Cohen D, Coco A. Declining trends in the provision of prenatal care visits by family physicians. Ann Fam Med. 2009;7:128–133. 28. Handley SC, Passarella M, Herrick HM, et al. Birth volume and geographic distribution of us hospitals with obstetric services from 2010 to 2018. JAMA Netw Open. 2021;4:e2125373. 29. Lisonkova S, Haslam MD, Dahlgren L, et al. Maternal morbidity and perinatal outcomes among women in rural versus urban areas. CMAJ. 2016;188:E456–E465. 30. Kozhimannil KB, Hung P, McClellan M, et al. Obstetric Services and Quality among Critical Access, Rural, and Urban Hospitals in Nine States. Center University of Minnesota Rural Health Research Center. 2013. 31. Mann S, McKay K, Brown H. The maternal health compact. N Engl J Med. 2017;376:1304–1305. 32. Pregnancy Mortality Surveillance System. Secondary pregnancy mortality surveillance system. 2022. Available at: https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm. Accessed April 17, 2022. 33. Creanga AA, Syverson C, Seed K, et al. Pregnancy-related mortality in the United States, 2011-2013. Obstet Gynecol. 2017;130:366–373. 34. Singh GK. Maternal Mortality in the United States, 1935-2007: Substantial Racial/Ethnic, Socioeconomic, and Geographic Disparities Persist. Rockville, MD: Health Resources and Services Administration, Maternal and Child Health Bureau; 2010. 35. Kozhimannil KB, Interrante JD, Henning-Smith C, et al. Rural-urban differences in severe maternal morbidity and mortality in the US, 2007-15. Health Aff. 2019;38:2077–2085. 36. Vale CCR, Almeida NKO, Almeida R. Association between prenatal care adequacy indexes and low birth weight outcome. Rev Bras Ginecol Obstet. 2021;43:256–263. 37. Dayal S, Fogel J, Griggs R. Adequacy of prenatal care and stillbirth. Minerva Obstet Gynecol. 2022;74:68–74;. 38. Nasiri K, Moodie EEM, Abenhaim HA. To what extent is the association between race/ethnicity and fetal growth restriction explained by adequacy of prenatal care? A mediation analysis of a retrospectively selected cohort. Am J Epidemiol. 2020;189:1360–1368. 39. Osterman MJK, Martin JA. Timing and adequacy of prenatal care in the United States, 2016. Natl Vital Stat Rep. 2018;67:1–14. 40. Deprez RD, Agger MS, McQuinn LB. Access to physicians, obstetric care use, and adequacy of prenatal care for medicaid patients in Maine: 1985-1989. Obstet Gynecol. 1996;88:443–450. 41. Miller MK, Clarke LL, Albrecht SL, et al. The interactive effects of race and ethnicity and mother’s residence on the adequacy of prenatal care. J Rural Health. 1996;12:6–18. 42. Gourevitch RA, Natwick T, Chaisson CE, et al. Variation in guideline-based prenatal care in a commercially insured population. Am J Obstet Gynecol. 2022;226:413 e1–13 e19. 43. Kozhimannil KB, Hung P, Henning-Smith C, et al. Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the United States. JAMA. 2018;319:1239–1247. 44. Shah NT. Eroding access and quality of childbirth care in rural US counties. JAMA. 2018;319:1203–1204. 45. Grzybowski S, Stoll K, Kornelsen J. Distance matters: a population based study examining access to maternity services for rural women. BMC Health Serv Res. 2011;11:147.