Deaths and life-threatening complications during childbirth are more likely in rural America than in urban areas, according to a first-of-its-kind analysis presented by University of Minnesota researchers in Washington, D.C., on Wednesday.
Previous studies by the U’s Katy Kozhimannil and others have shown growing problems in rural obstetric care, but the new research is the first to confirm the fear that rural mothers are more at risk for severe childbirth outcomes.
“Geography affects maternal health risks,” Kozhimannil said Wednesday at a research symposium on rural health organized by the journal Health Affairs, which also published her results.
The key finding — that rural mothers have a 9% greater risk of life-threatening complications or deaths from childbirth — was based on a review of birth outcomes across the United States from 2007 through 2015. The disparity translates into 4,378 additional childbirth deaths and near-death complications among rural mothers during that period.
Kozhimannil said that is a problem, considering that even the urban rate of childbirth complications is “unacceptably high.”
What the findings mean for Minnesota is unclear, because the research did not break down rural-urban disparities for each state.
But health officials in Minnesota said the research underscores the problem of declining rural access as small hospitals stop performing scheduled deliveries due to low patient numbers and liability and insurance risks.
At least 13 hospitals in rural Minnesota communities, including Grand Marais in the northeast and Springfield in the southwest, have stopped scheduling deliveries over the past decade, though they remained equipped for emergencies.
Even so, 67% of Minnesota’s acute care hospitals continue to schedule deliveries, which is higher than the national average, said Dr. Rahul Koranne, chief medical officer for the Minnesota Hospital Association. Among the 83 hospitals that still deliver babies, 95% are following evidence-based guidance about treating mothers with opioid addictions, and 81% are following guidelines to address childbirths in which mothers suffer hemorrhages or excessive bleeding.
The latter is particularly relevant to Kozhimannil’s study, which found blood transfusion problems in a majority of cases of maternal complications or deaths overall, and in a greater share of the rural cases.
Koranne said that while he’s proud so many Minnesota hospitals have maintained their OB services for rural mothers, it’s important that they maintain high standards and that hospital and community leaders should consider discontinuing that service if standards can’t be met. “Our mission is to have a healthy mom and a healthy baby at the end of every single pregnancy,” he said. “If that’s the bar, these are the trade-offs that need to be made.”
Shutting down OB services might eliminate risks for a hospital, but Kozhimannil pointed out it does not necessarily reduce risk for the mothers — who are still delivering babies and having to travel farther. Her prior research found that expecting mothers received less prenatal care in communities where hospitals had stopped delivering babies.
“The hospital no longer holds the risk of a birth gone wrong,” she said, “but that risk doesn’t leave that community.”
While rural patients will always have longer distances and less immediate access to health care, Kozhimannil said that doesn’t excuse the disparity in severe outcomes and that effective solutions require more input and involvement from rural leaders.
Rural expecting mothers might have to anticipate longer drives or delays in epidural anesthesia during labor, she said, but nothing more severe.
“Maybe [living in a rural area] ought to be a risk for something a little short of dying or almost dying.”