Maternal morbidity and perinatal outcomes among women in rural versus urban areas.
BACKGROUND
Most studies examining geographic barriers to maternity care in industrialized countries have focused solely on fetal and neonatal outcomes. We examined the association between rural residence and severe maternal morbidity, in addition to perinatal mortality and morbidity.


METHODS
We conducted a retrospective population-based cohort study of all women who gave birth in British Columbia, Canada, between Jan. 1, 2005, and Dec. 31, 2010. We compared maternal mortality and severe morbidity (e.g., eclampsia) and adverse perinatal outcomes (e.g., perinatal death) between women residing in areas with moderate to no metropolitan influence (rural) and those living in metropolitan areas or areas with a strong metropolitan influence (urban). We used logistic regression analysis to obtain adjusted odds ratios (ORs) and 95% confidence intervals (CIs).


RESULTS
We found a significant association between death or severe maternal morbidity and rural residence (adjusted OR 1.15, 95% CI 1.03-1.28). In particular, women in rural areas had significantly higher rates of eclampsia (adjusted OR 2.70, 95% CI 1.79-4.08), obstetric embolism (adjusted OR 2.16, 95% CI 1.14-4.07) and uterine rupture or dehiscence (adjusted OR 1.96, 95% CI 1.42-2.72) than women in urban areas. Perinatal mortality did not differ significantly between the study groups. Infants in rural areas were more likely than those in urban areas to have a severe neonatal morbidity (adjusted OR 1.14, 95% CI 1.02-1.29), to be born preterm (adjusted OR 1.06, 95% CI 1.01-1.11), to have an Apgar score of less than 7 at 5 minutes (adjusted OR 1.24, 95% CI 1.13-1.31) and to be large for gestational age (adjusted OR 1.14, 95% CI 1.10-1.19). They were less likely to be small for gestational age (adjusted OR 0.90, 95% CI 0.85-0.95) and to be admitted to an neonatal intensive care unit (NICU) (adjusted OR 0.36, 95% CI 0.33-0.38) compared with infants in urban areas.


CONCLUSIONS
Compared with women in urban areas, those in rural areas had higher rates of severe maternal morbidity and severe neonatal morbidity, and a lower rate of NICU admission. Maternity care providers in rural regions need to be aware of potentially life-threatening maternal and perinatal complications requiring advanced obstetric and neonatal care.
Department of Obstetrics and Gynaecology (Lisonkova, Dahlgren, Lim), University of British Columbia and the Children's and Women's Health Centre of British Columbia; School of Population and Public Health (Lisonkova, Haslam), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynecology (Chen), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Synnes), University of British Columbia, Vancouver, BC slisonkova@cfri.ca.
Sarka
S
Lisonkova
Department of Obstetrics and Gynaecology (Lisonkova, Dahlgren, Lim), University of British Columbia and the Children's and Women's Health Centre of British Columbia; School of Population and Public Health (Lisonkova, Haslam), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynecology (Chen), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Synnes), University of British Columbia, Vancouver, BC.
Matthew D
MD
Haslam
Department of Obstetrics and Gynaecology (Lisonkova, Dahlgren, Lim), University of British Columbia and the Children's and Women's Health Centre of British Columbia; School of Population and Public Health (Lisonkova, Haslam), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynecology (Chen), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Synnes), University of British Columbia, Vancouver, BC.
Leanne
L
Dahlgren
Department of Obstetrics and Gynaecology (Lisonkova, Dahlgren, Lim), University of British Columbia and the Children's and Women's Health Centre of British Columbia; School of Population and Public Health (Lisonkova, Haslam), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynecology (Chen), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Synnes), University of British Columbia, Vancouver, BC.
Innie
I
Chen
Department of Obstetrics and Gynaecology (Lisonkova, Dahlgren, Lim), University of British Columbia and the Children's and Women's Health Centre of British Columbia; School of Population and Public Health (Lisonkova, Haslam), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynecology (Chen), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Synnes), University of British Columbia, Vancouver, BC.
Anne R
AR
Synnes
Department of Obstetrics and Gynaecology (Lisonkova, Dahlgren, Lim), University of British Columbia and the Children's and Women's Health Centre of British Columbia; School of Population and Public Health (Lisonkova, Haslam), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynecology (Chen), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Synnes), University of British Columbia, Vancouver, BC.
Kenneth I
KI
Lim
D000293:Adolescent; D000328:Adult; D001034:Apgar Score; D001955:British Columbia / Q000453:epidemiology; D015331:Cohort Studies; D004461:Eclampsia / Q000453:epidemiology; D004617:Embolism / Q000453:epidemiology; D005260:Female; D005320:Fetal Macrosomia / Q000453:epidemiology*; D006700:Home Childbirth / Q000706:statistics & numerical data; D006801:Humans; D007231:Infant, Newborn; D007236:Infant, Small for Gestational Age; D016015:Logistic Models; D008428:Maternal Mortality; D008880:Midwifery / Q000706:statistics & numerical data; D009774:Obstetrics / Q000706:statistics & numerical data; D016017:Odds Ratio; D054238:Perinatal Mortality; D010821:Physicians, Family / Q000706:statistics & numerical data; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology*; D047928:Premature Birth / Q000453:epidemiology*; D012189:Retrospective Studies; D012424:Rural Population / Q000706:statistics & numerical data*; D014505:Urban Population / Q000706:statistics & numerical data*; D014597:Uterine Rupture / Q000453:epidemiology; D055815:Young Adult
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