Rural–Urban Differences Abound for Induced, Cesarean Births

Larry Hand

December 17, 2013

Labor-induced births for no medical reason increased at a relative rate of 77.7% at rural US hospitals from 2002 through 2010 compared with a relative rate increase of 17.3% for urban hospitals, according to an article published in the January 2014 issue of Medical Care.

With as many births that take place in the United States every year, the trends have major health, policy and financial implications as current health reform measures go into effect, and rural–urban differences should be considered when implementing payment policies, the researchers write.

Katy B. Kozhimannil, PhD, MPA, from the Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, and colleagues analyzed records on almost 7.2 million births (6.3 million urban, 837,772 rural) between 2002 and 2010. The records were in the National Inpatient Sample database, a uniform database to support comparative health services research that has been available since 1998. The records constitute a 20% sample of US hospitals.

During that time, nonindicated labor induction, or induction for no medical reason, increased from 9.3% in 2002 to 16.5% in 2010 in rural hospitals and from 10.3% to 12.0% in urban hospitals. Nonindicated cesarean birth rates increased from 14.3% to 16.9% in rural hospitals and from 14.3% to 17.8% in urban hospitals.

In models adjusted for sociodemographic factors, women giving birth in rural hospitals were more likely to be younger (52.9% younger than 25 years rural vs 37.5% urban), white (46.9% rural vs 38.5% urban), and covered by Medicaid (50.9% rural vs 39.3% urban).

In unadjusted analyses, cesarean rates increased from 12.9% to 15.5% for low-risk women in rural hospitals and from 12.7% to 16.1% for low-risk women in urban hospitals. Vaginal delivery after caesarean birth rates decreased from 9.3% to 5% in rural hospitals and from 18.8% to 10.0% in urban hospitals.

Consideration for All

"This analysis offers important insight into obstetric care trends in rural and urban hospitals," the researchers write. "Rising cesarean rates for low-risk pregnancies and nonindicated cesareans are challenges for both rural and urban hospitals.... These findings provide clinicians, hospital administrators, and policymakers an opportunity to address disparate trends between rural and urban settings and to improve maternity care quality."

"With approximately four million births per year in the United States, a one percentage point difference in the use of a procedure affects 40,000 women and infants annually," Dr Kozhimannil commented in a journal news release. "Based on our findings, we estimate that differences due to rural or urban location — rather than differences in patient or hospital characteristics — may affect between 24,000 and 200,000 mothers and their babies each year."

This research was supported by the Rural Health Center Grant Program Cooperative Agreement from the Health Resources and Services Management Administration, the Building Interdisciplinary Research Careers in Women's Health Grant from the Eunice Kennedy Shriver National Institute of Child Health and Development, the Office of Research on Women's Health, and the National Institute on Aging. The authors have disclosed no relevant financial relationships.

Med Care. 2014;52:4-9. Abstract

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