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Rural-Urban Differences in Obstetric Care, 2002–2010, and Implications for the Future

Kozhimannil, Katy B. PhD, MPA*,†; Hung, Peiyin MSPH*,†; Prasad, Shailendra MBBS, MPH†,‡; Casey, Michelle MS*,†; Moscovice, Ira PhD*,†

doi: 10.1097/MLR.0000000000000016
Brief Report

Background: Approximately 15% of the 4 million annual US births occur in rural hospitals.

Objective: To (1) measure differences in obstetric care in rural and urban hospitals, and to (2) examine whether trends over time differ by rural-urban hospital location.

Research Design and Subjects: This was a retrospective analysis of hospital discharge records for all births in the 2002–2010 Nationwide Inpatient Sample, which constitutes 20% sample of US hospitals (N=7,188,972 births: 6,316,743 in urban hospitals, 837,772 in rural hospitals).

Measures: Rates of low-risk cesarean (full-term, singleton, vertex pregnancies; no prior cesarean), vaginal birth after cesarean (VBAC), nonindicated cesarean, and nonindicated labor induction were estimated.

Results: In 2010, low-risk cesarean rates in rural and urban hospitals were 15.5% and 16.1%, respectively, and nonindicated cesarean rates were 16.9% and 17.8%, respectively. VBAC rates were 5.0% in rural and 10.0% in urban hospitals in 2010. Between 2002 and 2010, rates of low-risk cesarean and nonindicated cesarean increased, and VBAC rates decreased in both rural and urban hospitals. Nonindicated labor induction was less frequent in rural versus urban hospitals in 2002 [adjusted odds ratio=0.79 (0.78–0.81)], but increased more rapidly in rural hospitals from 2002 to 2010 [adjusted odds ratio=1.05 (1.05–1.06)]. In 2010, 16.5% of rural births were induced without indication (12.0% of urban births).

Conclusions: From 2002 to 2010, cesarean rates rose and VBAC rates fell in both rural and urban hospitals. Nonindicated labor induction rates rose disproportionately faster in rural versus urban settings. Tailored clinical and policy tools are required to address differences between rural and urban hospitals.

Supplemental Digital Content is available in the text.

*Division of Health Policy and Management, University of Minnesota School of Public Health

Division of Health Policy and Management, University of Minnesota Rural Health Research Center

Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN

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Supported by the Rural Health Research Center Grant Program Cooperative Agreement from the Health Resources and Services Administration (U1CRH03717-09-00). This work was also supported by the Building Interdisciplinary Research Careers in Women’s Health Grant (K12HD055887) from the Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD), the Office of Research on Women’s Health, and the National Institute on Aging, at the National Institutes of Health, administered by the University of Minnesota Deborah E. Powell Center for Women’s Health.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Health Resources and Services Administration.

The authors declare no conflict of interest.

Reprints: Katy B. Kozhimannil, PhD, MPA, Division of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware St. SE, MMC 729, Minneapolis, MN 55455. E-mail:

© 2014 by Lippincott Williams & Wilkins.