title: Impact of rurality on maternal and infant health indicators and outcomes in Maine.
abstract: BACKGROUND
  Rural residents may face health challenges related to geographic barriers to care, physician shortages, poverty, lower educational attainment, and other demographic factors. In maternal and child health, these disparities may be evidenced by the health risks and behaviors of new mothers, the health of infants born to these mothers, and the care received by both mothers and infants.
  
  
  METHODS
  To determine the impact of rurality on maternal and child health in Maine, USA, 11 years of data (2000-2010) for the state of Maine from the Pregnancy Risk Assessment Monitoring System (PRAMS) project were analyzed. PRAMS is a national public health surveillance system that uses questionnaires to survey women who had delivered live infants in the previous 2-4 months. Using a geographic information system, each questionnaire response was assigned a rurality tier (urban, suburban, large rural town, or isolated rural community) based on the rural-urban commuting area code of the town of residence of the mother. Results from the four rurality tiers were compared using the survey procedures in Statistical Analysis Software to adjust for the complex sampling strategy of the PRAMS dataset. Means (for continuous variables) and percentages (for categorical variables) were calculated for each rurality tier, along with 95% confidence intervals. Significant differences between rurality tiers were tested for using F-tests or χ2 tests. If significant differences between rurality tiers existed (p<0.05), specific tiers were judged to be different from each other if their 95% confidence intervals did not overlap.
  
  
  RESULTS
  A total of 12 600 mothers responded to the PRAMS questionnaire during the study period. Compared to mothers from more urban areas, rural mothers were younger (10.5% of mothers from isolated rural areas were teenagers compared to 6.2% of mothers from urban areas), less well educated, less likely to be married, and more likely to live in lower income households (39.6% of isolated rural mothers had household incomes ≤US$20 000/year vs 28.8% of urban mothers). Rural mothers had higher pre-pregnancy body mass indexes (BMIs; average BMI 26.1 for isolated rural women vs 25.3 for urban women) and were more likely to smoke but less likely to drink alcohol (both before and during pregnancy). Compared to mothers from more urban areas, rural mothers were not sure they were pregnant until a later gestational age but received prenatal care just as early and were just as likely to receive prenatal care as early as they wished. There were no differences among rurality tiers in Caesarean section rates, rates of premature births (<37 weeks gestation), or rates of underweight births (<2500 g). However infants born to rural mothers were less likely to be breastfed (52.9% of isolated rural vs 60.9% of urban infants breast fed for ≥8 weeks).
  
  
  CONCLUSIONS
  These results show that, while rural women face significant demographic and behavior challenges, their access to prenatal care, the care they receive while pregnant, and the outcomes of their pregnancies are similar to those of urban women. These results highlight areas where focused pre-pregnancy and prenatal education may improve maternal and child health in rural Maine.
authors.affiliation: School of Nursing, University of Southern Maine, Portland, Maine, USA. deharris@usm.maine.edu.
authors.forename: David E
authors.initials: DE
authors.lastname: Harris
authors.affiliation: Department of Mathematics and Statistics, University of Southern Maine, Portland, Maine, USA. aaboueissa@usm.maine.edu.
authors.forename: AbouEl-Makarim
authors.initials: AM
authors.lastname: Aboueissa
authors.affiliation: School of Nursing, University of Southern Maine, Portland, Maine, USA. nbaugh@usm.maine.edu.
authors.forename: Nancy
authors.initials: N
authors.lastname: Baugh
authors.affiliation: School of Nursing, University of Southern Maine, Portland, Maine, USA. csarton@usm.maine.edu.
authors.forename: Cheryl
authors.initials: C
authors.lastname: Sarton
mesh_terms: D000293:Adolescent; D000328:Adult; D015992:Body Mass Index; D005260:Female; D005865:Gestational Age; D015438:Health Behavior; D006305:Health Status Indicators; D054625:Healthcare Disparities / Q000706:statistics & numerical data; D006801:Humans; D000068104:Infant Health / Q000592:standards / Q000706:statistics & numerical data*; D008281:Maine; D000068097:Maternal Health / Q000592:standards / Q000706:statistics & numerical data*; D015233:Models, Statistical; D011159:Population Surveillance; D011247:Pregnancy; D011256:Pregnancy Outcome; D011253:Pregnancy in Adolescence / Q000706:statistics & numerical data; D018570:Risk Assessment; D012423:Rural Health / Q000592:standards*; D012424:Rural Population / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D014505:Urban Population / Q000706:statistics & numerical data*; D055815:Young Adult
keywords: Evidence-based Care; Maternal and Child Health; Medical; North America; Public Health