# Risk-Appropriate Childbirth Care Among Higher-Risk Pregnant Rural Residents

## TL;DR

Higher-risk pregnant rural residents often don't receive appropriate childbirth care, with disparities linked to race, insurance, education, and distance from hospitals.

## Contribution

Identifies factors associated with lack of risk-appropriate childbirth care for higher-risk rural pregnant populations.

## Key findings

- 54.4% of higher-risk rural pregnant residents received risk-appropriate care for level II conditions.
- American Indian/Alaska Native and Hispanic individuals had higher rates of not receiving appropriate care.
- Distance to the nearest hospital significantly impacted access to risk-appropriate care.

## Abstract

What proportion of pregnant rural residents receive risk-appropriate childbirth care, and what factors are associated with not receiving risk-appropriate care?

In this cross-sectional study of nearly 200 000 pregnant rural residents with higher-risk conditions, as clinical complexity increased, the proportion receiving risk-appropriate care decreased. Identifying as American Indian or Alaska Native or as Hispanic, being younger, having lower educational attainment, having public insurance or no insurance, and living further from a risk-appropriate hospital were factors significantly associated with not receiving risk-appropriate care.

These findings highlight the need for reducing distance to local childbirth care and increasing access to subspecialty care for pregnant rural residents.

This cross-sectional study assesses the proportion of higher-risk pregnant rural residents in the US who receive risk-appropriate childbirth care and identifies facrots associated with not receiving risk-appropriate care.

With hospital-based obstetric care declining in rural areas, risk-appropriate care, which aligns patient clinical conditions with hospital capabilities using level of care, may be limited for pregnant rural residents, especially those with higher-risk conditions that necessitate specialty or subspecialty obstetric care.

To assess the proportion of higher-risk pregnant rural residents who receive risk-appropriate care during childbirth and identify factors associated with not receiving risk-appropriate care.

This cross-sectional study used linked vital statistics and hospital discharge data for pregnant rural residents with higher-risk clinical conditions who had hospital-based births in Michigan (2010-2020), Oregon (2010-2020), Pennsylvania (2010-2018), and South Carolina (2010-2020). Data analyses were performed between December 2023 and July 2025.

Birth hospital maternal level of care (I, basic; II, specialty; III, subspeciality; IV, regional perinatal).

The main outcome was birth in a hospital with risk-appropriate care, defined as having the necessary level of care for the patient’s clinical condition. Covariates included age, race and ethnicity, insurance, education, prenatal care utilization, medical and obstetric comorbidities, distance to the closest risk-appropriate hospital (quartile 1: 0.50-5.57 miles, quartile 2: 5.58-18.90 miles, quartile 3: 18.91-33.93 miles, quartile 4: 33.94-209.80 miles), year, and state.

A total of 199 225 higher-risk pregnant rural residents (mean [SD] maternal age, 27.9 [5.6] years) were included, of whom 11 651 (5.9%) identified as Hispanic, 3054 (1.5%) as non-Hispanic American Indian or Alaska Native, 1370 (0.7%) as non-Hispanic Asian or Pacific Islander, 18 296 (9.2%) as non-Hispanic Black, 5320 (2.7%) as non-Hispanic other race, and 159 253 (79.9%) as non-Hispanic White. Birth at a risk-appropriate hospital occurred for 38 441 of 70 647 individuals (54.4%) with conditions requiring level II care, 4611 of 9270 (49.7%) with conditions requiring level III care, and 1793 of 6527 (27.5%) with conditions requiring level IV care. Those with significantly higher rates of not receiving risk-appropriate care included American Indian or Alaska Native (adjusted incidence rate ratio [aIRR], 1.13; 95% CI, 1.10-1.17), or Hispanic (aIRR, 1.06; 95% CI, 1.03-1.08) individuals (compared with White individuals), those without private insurance (public: aIRR, 1.03; 95% CI, 1.01-1.04; uninsured: aIRR, 1.07; 95% CI, 1.01-1.14), those who were younger and had less education (age <20 years: aIRR, 1.05; 95% CI, 1.03-1.08, compared with 30-34 years; some high school: aIRR, 1.04; 95% CI, 1.03-1.06, compared with high school degree), and those who lived further from a risk-appropriate hospital (furthest quartile: aIRR, 23.86; 95% CI, 20.48-27.79, compared with closest quartile).

In this study, lack of risk-appropriate care was common for pregnant rural residents with clinical complexity. Associated factors, including race, ethnicity, insurance, age, education, and distance, highlight the barriers and need for increasing access to subspecialty care for pregnant rural residents.