Original Research

Obstetric outcomes among rural parturients across urban and rural hospitals


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Courtney L Strickland
1 MD, Clinical Assistant Professor * ORCID logo

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Dmitry Tumin
2 PhD, Associate Professor ORCID logo

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Alyssa Harris
3 MPH, Research Analytics Director ORCID logo

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Hannah Murphy
4 PhD, Research Analytics Lead Analyst ORCID logo

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James L Whiteside
5 MD, MA, MHA, Professor and Department Chair ORCID logo


1, 5 Department of Obstetrics and Gynecology, Brody School of Medicine, East Carolina University, 600 Moye Blvd, Greenville, NC 27834, USA

2 Department of Pediatrics, Brody School of Medicine, East Carolina University, 600 Moye Blvd, Greenville, NC 27834, USA

3, 4 Center for Advanced Analytics and Informatics, Vizient Inc., 433 West Van Buren St, Chicago, IL 60607, USA

ACCEPTED: 12 June 2024

early abstract:

Introduction: The objective of this study is to evaluate severe maternal morbidity (SMM) of rural parturients delivering at rural compared to urban hospitals in the United States.
Methods: We identified patients aged 18-40 in a multi-institutional claims database who lived in a rural ZIP code and delivered at a rural or urban hospital between 2015Q4 and 2022Q4. The primary outcome was SMM, and the secondary outcome was SMM exclusive of blood transfusions. We combined exact ZIP code matching and propensity score matching to compare SMM risk among patients living in the same rural community and delivering in urban as compared to rural hospitals.
Results: 214,296 patients from 571 ZIP codes were identified, including 47% delivering at rural facilities and 53% delivering at urban facilities. The SMM rate was 1.1% (0.3% excluding blood transfusions). After matching, urban vs. rural delivery was associated with increased odds of SMM other than blood transfusion (OR:2.44; 95% CI:1.81, 3.28), but was not associated with differences in risk of any SMM.
Conclusion: There was no evidence of reduced SMM for rural patients delivering at an urban rather than a rural hospital. SMM exclusive of blood transfusions was increased for rural patients delivering at urban hospitals after matching on ZIP code and predictors of urban hospital delivery. Our findings undermine the assumption that delivery at a rural facility has inherently greater risks relative to delivery at an urban facility. As some health systems face challenges to maintain rural labor & delivery units, patient safety must be considered if confronted with the possibility of unit or hospital closures.
Keywords: delivery of health care, health facilities, population characteristics, reproductive medicine