# Severe Maternal Morbidity and Mortality After Delivery Hospitalization Among Rural Residents Bypassing Local Care for Urban Hospitals

## TL;DR

Rural women who give birth at urban hospitals face higher risks of severe maternal complications and death compared to those delivering locally or in urban areas.

## Contribution

The study reveals that rural nonlocal births have higher postpartum severe maternal morbidity and mortality risks than urban and rural local births.

## Key findings

- Rural nonlocal deliveries had the highest SMMM risk (180.0 per 10,000 births) compared to urban and rural local deliveries.
- Adjusting for factors still showed a 1.18 higher risk for rural nonlocal vs urban deliveries.
- Rural local deliveries had SMMM risks comparable to urban births.

## Abstract

This cohort study compares risk of severe maternal morbidity and mortality among women in South Carolina who bypassed local communities for delivery at urban hospitals (nonlocal delivery) vs a local rural or urban hospital.

Do rural residents who bypassed local communities for delivery at urban hospitals (nonlocal delivery) have higher postpartum severe maternal morbidity and mortality (SMMM) than rural local and urban births?

In this cohort study of 235 375 births in South Carolina, nearly one-half of rural deliveries occurred at nonlocal hospitals. Rural nonlocal deliveries had the highest 1-year postpartum SMMM risk, even after adjusting for maternal and hospital factors.

In this cohort study, rural nonlocal births were more likely to experience SMMM than urban and rural local births, underscoring the need for targeted discharge planning and postpartum care coordination for rural deliveries in nonlocal settings.

Rural residents experience higher severe maternal morbidity and mortality (SMMM) and limited local hospital obstetric supply. However, data on postpartum SMMM among these rural residents bypassing local communities for childbirth are limited.

To estimate postpartum SMMM among urban, rural nonlocal, and rural local births.

This retrospective population-based cohort study identified all childbirth deliveries and hospitalization discharges from January 1, 2018, to December 31, 2022, in South Carolina and followed-up to 1-year postpartum using data from all-payer hospital inpatient, outpatient, and emergency department visits linking to vital records for birth and death certificates information. Data were analyzed from March to September 2025.

Urban residency, rural residency with nonlocal birth (ie, urban hospital deliveries), and rural residency with local birth (deliveries at in-county or adjacent rural hospitals), classified using the 2023 Rural-Urban Continuum Codes definitions (1-3, urban; 4-9, rural).

The primary outcomes of postpartum SMMM—severe maternal morbidity (SMM) and/or pregnancy-associated mortality—were identified using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis and procedure codes and death certificates, respectively. Cox proportional hazards models compared cumulative incidence and timing of postpartum SMMM across exposure groups.

Of 235 375 deliveries to 197 216 women (mean [SD] maternal age, 28.3 [5.8] years), 203 325 (86.4%) were to urban residents, 15 053 (6.4%) were to rural residents bypassing local birth sites for urban hospitals, and 16 997 (7.2%) were to rural residents delivering locally, yielding a 47.0% bypassing rate for rural residents. SMMM was highest among rural nonlocal deliveries (180.0 per 10 000 births), followed by similar rates for urban (118.8 per 10 000 births) and rural local deliveries (114.7 per 10 000 births). Adjustment for maternal sociodemographic characteristics, clinical factors, and hospital characteristics still showed higher SMMM risk for rural nonlocal vs urban deliveries (adjusted hazard ratio, 1.18; 95% CI, 1.04-1.33), while the risk associated with rural local vs urban delivery was not significantly different.

In this cohort study of 2018 to 2022 childbirth deliveries in South Carolina, rural local deliveries had SMMM risks comparable to urban births, but rural nonlocal deliveries were associated with increased risk. These findings suggest that targeted interventions (eg, strengthening rural obstetric care supply, childbirth discharge planning, postpartum care coordination, and timely follow-up) may help mitigate these disparities for rural nonlocal births.