Rural Residence and Adverse Pregnancy Outcomes in the United States: Epidemiologic Insights and Perspectives

Abstract

Adverse pregnancy outcomes (APOs) such as hypertensive disorders of pregnancy, gestational diabetes, preterm birth, restricted intrauterine growth, and intrauterine fetal demise are often associated with pregnancy-related mortality and maternal mortality. Furthermore, APOs complicate the care of pregnant women, leading to worse short- and long-term outcomes, especially for women from underserved areas. However, the occurrence of APOs has received considerably less attention in rural areas, which are often socioeconomically disadvantaged and are burdened by significant health disparities. This review article provides epidemiologic insights into the distribution and potential determinants of APOs among women living in rural communities in the United States. Additionally, it addresses intrinsic and extrinsic factors pertaining to biology, social factors, and environmental factors that potentially influence the incidence of APOs in rural areas. Finally, the success of interventions implemented to improve access to health care to reduce APOs, perspectives, and challenges posed by APOs among women living in rural areas are also discussed.

Key Points

• APOs lead to substantial morbidity and mortality.

• Several APOs are less studied in rural populations.

• Rural areas often have significant health disparities that influence pregnancy outcomes.

• More epidemiological studies of APOs in rural areas are needed.

Keywords

adverse pregnancy outcomes - epidemiology - women - rural population - maternal mortality

Contributors' Statement

D.A.: Conceptualization, writing—original draft, writing—review and editing, supervision. R.D.S.: Conceptualization, writing—original draft. N.H.: Conceptualization, writing—original draft. B.O.: Conceptualization, writing—original draft. M.S.: Conceptualization, writing—original draft. O.E.O.: Conceptualization, writing—original draft.

Note

Portions of this manuscript were published in the Texas Tech University Health Sciences Center's Rural Health Quarterly magazine, with permission granted to publish this work in a peer-reviewed journal.

Publikationsverlauf

Eingereicht: 03. Juli 2025

Angenommen: 26. Oktober 2025

Accepted Manuscript online:
28. Oktober 2025

Artikel online veröffentlicht:
04. November 2025

• References

• 1 Basile Ibrahim B, Kozhimannil KB. Racial disparities in respectful maternity care during pregnancy and birth after cesarean in rural United States. J Obstet Gynecol Neonatal Nurs 2023; 52 (01) 36-49
• 2 Kozhimannil KB, Hung P, Casey MM, Lorch SA. Factors associated with high-risk rural women giving birth in non-NICU hospital settings. J Perinatol 2016; 36 (07) 510-515
• 3 Crump C, Sundquist J, Sundquist K. Adverse pregnancy outcomes and long-term mortality in women. JAMA Intern Med 2024; 184 (06) 631-640
• 4 Rural Health Information Hub. Rural Data Explorer: Total Physicians per 10,000 People. 2022 . Accessed June 21, 2025 at: https://www.ruralhealthinfo.org/data-explorer?id=205
• 5 American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 586: Health disparities in rural women. Obstet Gynecol 2014; 123 (2 Pt 1): 384-388
• 6 Lisonkova S, Haslam MD, Dahlgren L, Chen I, Synnes AR, Lim KI. Maternal morbidity and perinatal outcomes among women in rural versus urban areas. CMAJ 2016; 188 (17-18): E456-E465
• 7 Harrington KA, Cameron NA, Culler K, Grobman WA, Khan SS. Rural-urban disparities in adverse maternal outcomes in the United States, 2016-2019. Am J Public Health 2023; 113 (02) 224-227
• 8 Mehrnoush V, Ranjbar A, Banihashemi F, Darsareh F, Shekari M, Shirzadfardjahromi M. Urban-rural differences in the pregnancy-related adverse outcome. Gynecol Obstet Clin Med 2023; 3 (01) 51-55
• 9 Rural Health Information Hub. Rural Maternal Health. Accessed June 18, 2025 at: https://www.ruralhealthinfo.org/topics/maternal-health#access
• 10 Shulman HB, D'Angelo DV, Harrison L, Smith RA, Warner L. The Pregnancy Risk Assessment Monitoring System (PRAMS): Overview of design and methodology. Am J Public Health 2018; 108 (10) 1305-1313
• 11 Centers for Disease Control and Prevention. Pregnancy Risk Assessment Monitoring System (PRAMS). Accessed September 22, 2025 at: https://www.cdc.gov/prams/about/index.html
• 12 Ford ND, Cox S, Ko JY. et al. Hypertensive disorders in pregnancy and mortality at delivery hospitalization - United States, 2017-2019. MMWR Morb Mortal Wkly Rep 2022; 71 (17) 585-591
• 13 Cameron NA, Molsberry R, Pierce JB. et al. Pre-pregnancy hypertension among women in rural and urban areas of the United States. J Am Coll Cardiol 2020; 76 (22) 2611-2619
• 14 Centers for Disease Control and Prevention. QuickStats: Percentage of Mothers with Gestational Diabetes,* by Maternal Age - National Vital Statistics System, United States, 2016 and 2021. MMWR Morb Mortal Wkly Rep 2023; 72 (01) 16
• 15 Venkatesh KK, Huang X, Cameron NA. et al. Rural-urban disparities in pregestational and gestational diabetes in pregnancy: Serial, cross-sectional analysis of over 12 million pregnancies. BJOG 2024; 131 (01) 26-35
• 16 Ali U, Cure L, Lewis RK, Rattani A, Hill T, Woods NK. Examining rurality and social determinants of health among women with GDM: A 15-year comprehensive population analysis. BMC Womens Health 2024; 24 (01) 467
• 17 Abraham K, Wilk N. Living with gestational diabetes in a rural community. MCN Am J Matern Child Nurs 2014; 39 (04) 239-245
• 18 Kaufmann RC, Smith T, Bochantin T, Khardori R, Evans MS, Steahly L. Failure to obtain follow-up testing for gestational diabetic patients in a rural population. Obstet Gynecol 1999; 93 (5 Pt 1): 734-737
• 19 Sheiner E. Gestational diabetes mellitus: Long-term consequences for the mother and child grand challenge: How to move on towards secondary prevention?. Front Clin Diabetes Healthc 2020; 1: 546256
• 20 Sonenberg A, Mason DJ. Maternity care deserts in the US. JAMA Health Forum 2023; 4 (01) e225541
• 21 Kamphof HD, Posthuma S, Gordijn SJ, Ganzevoort W. Fetal growth restriction: Mechanisms, epidemiology, and management. Matern Fetal Med 2022; 4 (03) 186-196
• 22 Ewing AC, Ellington SR, Shapiro-Mendoza CK, Barfield WD, Kourtis AP. Full-term small-for-gestational-age newborns in the U.S.: Characteristics, trends, and morbidity. Matern Child Health J 2017; 21 (04) 786-796
• 23 Strutz KL, Dozier AM, van Wijngaarden E, Glantz JC. Birth outcomes across three rural-urban typologies in the Finger Lakes region of New York. J Rural Health 2012; 28 (02) 162-173
• 24 D'Agostin M, Di Sipio Morgia C, Vento G, Nobile S. Long-term implications of fetal growth restriction. World J Clin Cases 2023; 11 (13) 2855-2863
• 25 Milosavljevic J, Pejcic A, Arsenijevic P. et al. Factors associated with fetal growth restriction and small for gestational age newborns. Ginekol Pol 2023; 94 (08) 645-653
• 26 Garcia KK, Hunter SK. Proposed solutions for improving maternal health care in rural America. Clin Obstet Gynecol 2022; 65 (04) 868-876
• 27 World Health Organization. Preterm birth. Accessed June 18, 2025 at: https://www.who.int/news-room/fact-sheets/detail/preterm-birth/
• 28 Probst J, Zahnd W, Breneman C. Declines in pediatric mortality fall short for rural US children. Health Aff (Millwood) 2019; 38 (12) 2069-2076
• 29 Kent ST, McClure LA, Zaitchik BF, Gohlke JM. Area-level risk factors for adverse birth outcomes: trends in urban and rural settings. BMC Pregnancy Childbirth 2013; 13: 129
• 30 Jesse DE, Swanson MS, Newton ER, Morrow J. Racial disparities in biopsychosocial factors and spontaneous preterm birth among rural low-income women. J Midwifery Womens Health 2009; 54 (01) 35-42
• 31 Bourque SL, Hannan KE, Handley SC. et al. Rural-urban disparities in mortality among US-born preterm infants. Hosp Pediatr 2025; 15 (06) 519-528
• 32 Hostetter M, Klein S. Restoring access to maternity care in rural America. The Commonwealth Fund. Accessed June 18, 2025 at: https://doi.org/10.26099/CYCC-FF50
• 33 Lorch SA, Rogowski J, Profit J, Phibbs CS. Access to risk-appropriate hospital care and disparities in neonatal outcomes in racial/ethnic groups and rural-urban populations. Semin Perinatol 2021; 45 (04) 151409
• 34 Makkar A, McCoy M, Hallford G, Escobedo M, Szyld E. A hybrid form of telemedicine: A unique way to extend intensive care service to neonates in medically underserved areas. Telemed J E Health 2018; 24 (09) 717-721
• 35 Riley T, Umoren R, Kotler A. et al. Disparities in access to healthcare services in a regional neonatal transport network. Int J Ind Ergon 2024; 99: 103526
• 36 Brantley MD, Davis NL, Goodman DA, Callaghan WM, Barfield WD. Perinatal regionalization: A geospatial view of perinatal critical care, United States, 2010-2013. Am J Obstet Gynecol 2017; 216 (02) 185.e1-185.e10
• 37 Lorch SA, Baiocchi M, Ahlberg CE, Small DS. The differential impact of delivery hospital on the outcomes of premature infants. Pediatrics 2012; 130 (02) 270-278
• 38 Shah KP, deRegnier RO, Grobman WA, Bennett AC. Neonatal mortality after interhospital transfer of pregnant women for imminent very preterm birth in Illinois. JAMA Pediatr 2020; 174 (04) 358-365
• 39 Arora P, Bajaj M, Natarajan G. et al. Impact of interhospital transport on the physiologic status of very low-birth-weight infants. Am J Perinatol 2014; 31 (03) 237-244
• 40 Wolfson C, Qian J, Creanga AA. Levels, trends, and risk factors for stillbirths in the United States: 2000-2017. Am J Perinatol 2024; 41 (S 01): e601-e611
• 41 Dongarwar D, Aggarwal A, Barning K, Salihu HM. Trends in stillbirths and stillbirth phenotypes in the United States: An analysis of 131.5 million births. Int J MCH AIDS 2020; 9 (01) 146-148
• 42 Adams A, Dongarwar D, Shay L. et al. Social determinants of health and risk of stillbirth in the United States. Am J Perinatol 2024; 41 (S 01): e477-e485
• 43 Moore J, Evans S, Rose CE. et al. Increased stillbirth rates and exposure to environmental risk factors for stillbirth in counties with higher social vulnerability: United States, 2015-2018. Matern Child Health J 2024; 28 (12) 2026-2036
• 44 Save the Children. Rural Child and Family Well-being Dashboards. Understanding Childhood in Rural America. Accessed July 1, 2025 at: https://www.rural-child-family-data.org/
• 45 Lisonkova S, Sheps SB, Janssen PA, Lee SK, Dahlgren L, Macnab YC. Birth outcomes among older mothers in rural versus urban areas: a residence-based approach. J Rural Health 2011; 27 (02) 211-219
• 46 Rossen LM, Ahrens KA, Womack LS, Uddin SFG, Branum AM. Rural-Urban Differences in Maternal Mortality Trends in the United States, 1999-2017: Accounting for the impact of the pregnancy status checkbox. Am J Epidemiol 2022; 191 (06) 1030-1039
• 47 Chen Y, Shiels MS, Uribe-Leitz T. et al. Pregnancy-related deaths in the US, 2018-2022. JAMA Netw Open 2025; 8 (04) e254325
• 48 Margerison CE, Wang X, Gemmill A, Goldman-Mellor S. Pregnancy-associated mortality during the pandemic: Disparities by rurality. Am J Prev Med 2025; 68 (01) 176-181
• 49 Joseph KS, Lisonkova S, Boutin A. et al. Maternal mortality in the United States: are the high and rising rates due to changes in obstetrical factors, maternal medical conditions, or maternal mortality surveillance?. Am J Obstet Gynecol 2024; 230 (04) 440.e1-440.e13
• 50 Petersen EE, Davis NL, Goodman D. et al. Vital signs: Pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017. MMWR Morb Mortal Wkly Rep 2019; 68 (18) 423-429
• 51 Merkt PT, Kramer MR, Goodman DA. et al. Urban-rural differences in pregnancy-related deaths, United States, 2011-2016. Am J Obstet Gynecol 2021; 225 (02) 183.e1-183.e16
• 52 Centers for Disease Control and Prevention. Working Together to Reduce Black Maternal Mortality. Accessed June 20, 2025, https://www.cdc.gov/womens-health/features/maternal-mortality.html
• 53 Waldman H, Zimmerman A. Maternal Health in Rural America. National Rural Health Association. Accessed June 20, 2025 at: https://www.ruralhealthinfo.org/resources/23201
• 54 Gordon RD, Kishi A, Brown JA. et al. Rural maternal health interventions: A scoping review and implications for best practices. J Rural Health 2025; 41 (01) e70007
• 55 U.S. Centers for Medicare and Medicaid Services. Improving Access to Maternal Health Care in Rural Communities. Issue Brief. Accessed September 22, 2025 at: www.cms.gov/about-cms/agency-information/omh/equity-initiatives/rural-health/09032019-maternal-health-care-in-rural-communities.pdf
• 56 Beatty KE, Balio CP, Francisco MM, Meit MB, Mathis SM. Distribution of Block Grant Funding: Considerations for Rural Communities. Rural Health Research Gateway. Accessed September 21, 2025 at: https://www.ruralhealthresearch.org/publications/1695
• 57 Rural Health Research Gateway. Challenges, Successes, and Sustainability of the 2019 Rural Maternity and Obstetrics Management Strategies (RMOMS) Programs. Accessed September 22, 2025 at: https://www.ruralhealthresearch.org/projects/1041
• 58 Yawn BP, Yawn RA. Preterm birth prevention in a rural practice. JAMA 1989; 262 (02) 230-233
• 59 Tancredi M, Chrusciel J, Zaouia S, Mergey V, Laplanche D, Sanchez S. Implementing telemedicine for the care of women with gestational diabetes mellitus in a rural hospital: an observational retrospective study. BMC Health Serv Res 2024; 24 (01) 1316
• 60 McCue K, Sabo S, Wightman P. et al. Impact of a community health worker (CHW) home visiting intervention on any and adequate prenatal care among ethno-racially diverse pregnant women of the US Southwest. Matern Child Health J 2022; 26 (12) 2485-2495
• 61 Jolles D, Stapleton S, Wright J. et al. Rural resilience: The role of birth centers in the United States. Birth 2020; 47 (04) 430-437