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Rural Residency as a Risk Factor for Severe Maternal Morbidity


Where a woman lives should not dictate the outcome of her pregnancy. However, this is not the case for women living in rural areas as geography affects their maternal health. Rural residency is a term that implies living in places far away from large towns or cities permanently for an extended period. Severe maternal morbidity (SMM) is an unanticipated effect during childbearing that results in major temporary or permanent consequences to a woman’s or newborn health. Pregnant women in the rural areas experience a declining access to obstetric services, education, racial and geographic disparity, and inadequate health care facilities and services fostering severe maternal morbidity and mortality during pregnancy and birthing.

Several questions are considered in determining whether rural residency is a risk factor for severe maternal morbidity. They include;

  1. Is there access to obstetric services?
  2. Is there formal education among pregnant women and their husbands.
  3. Is there enough workforce in the maternal health sector in the rural areas?
  4. Are individuals in the rural areas insured?
  5. Is there good infrastructure in rural areas?
  6. Are there any disparities in rural areas?
  7. How are diverse cultures addressed?

In the USA, there is an increasing number of women suffering from pregnancy related mortality. According to research by Katon et al., (2019), the number of deaths among pregnant and birthing mothers has doubled since 1987 from 7.2 to 17.4 deaths per 100,000 live births. Besides, there is an increasing geographic disparity where Americans living in rural areas experience more maternal mortality compared to urban residents. According to Hansen et al. (2022), close to 700 women die annually due to pregnancy complications. According to research, in 2014 there were 50,000 women who experienced severe maternal morbidity (SMM) during their delivery. Hansen et al. (2022), affirm that rural women exhibit a complex risk profile exposing then to elevated risks of SMM. Indeed, In the USA, maternal mortality continues to increase, indicating the nation has severe maternal crisis which requires urgent intervention.

Declining Access to Obstetric Amenities

Rural areas encounter declining access to obstetric amenities. A study by ANNE affirm that in 2004, more than 50% of rural health care centers lacked hospital based obstetric services. Moreover, bwteen 2004/2014, 9% of hospitals experiences loss of in hospital based obstetric services.Obstetric services include preconception counseling, postpartum, prenatal care, delivery care, and education regarding breastfeeding. Failure to receive these services leads to premature pregnancy, low weight at birth, and even child mortality due to infections in perinatal and postnatal periods. Research by Hansen et al., (2022), affirm that women living in rural areas experience poor preconception health, leading to poor prenatal health. These expectant mothers are at risk of increased chronic illnesses compared to those living in urban areas. Besides, rural women suffer life threatening SMM diagnoses of uterine rupture, obstetric embolism and eclampsia (Hansen et al., 2022). Due to lack of adequate access to care facilitated by lack of health care professionals, insurance, and health literacy, rural women experience increased maternal morbidity. However, rural hospitals face financial challenges, thus difficulty providing obstetric care (Kozhimannil et al., 2019). Obstetric care services are essential,and ensure that a patient’s chronic conditions are stabilized early. Indeed, early treatment is a platform to combating chronic and other pregnancy related illnesses, and reducing complications during birth. Therefore, it is vital to develop local programs targeting expectant mothers that constantly need prenatal care to avoid maternal morbidity. Even though a person’s residence should not dictate pregnancy outcomes, it is evident that it does. Rural residents face maternal risks compared to urban residents.

Lack of formal Education

Teenage and young girls in rural areas have limited access to sex education, increasing the risk of teen pregnancy. In rural areas, some parts observe religious norms that do not allow sex education. When young girls fail to get educated on consequences of sex, when they become sex active, they lack knowledge on protective measures, such as the use of contraceptives, and engage in unsafe sex. Being pregnant at an early age, and considering other factors such as race, poverty, health disparities, and low economic socioeconomic status, these young girls become at risk of adverse maternal health outcomes. Reserach by Rajbanshi et al.,( 2021) state that education is essential for the population to care for their individual health. Studies have shown that women with secondary or higher education were less likely to develop SMM compared to women with no or primary education. Educated women have an increased degree of health concern and are aware of the importance of receiving adequate health care. Thus, educated women seek proactive maternal health care and give birth in settings with competent medical staff and well equipped facilities.

Low formal education has contributed to an increased risk of maternal morbidity. Sticking to traditional beliefs leads to increased maternal morbidity. Men who are decision-makers in every family should be given priority by educating them on pregnancy and delivery preparedness issues as their choices affect the survival of pregnant women. In contrast, increasing women’s education increases their need for antenatal health care use. Literate women have excellent cognitive skills, make vital decisions during their pregnancies, and follow doctor instructions to avoid maternal morbidity (Weitzman,2017). Indeed formal education has a positive relationship with maternal morbidity.

Lack of enough and adequate workforce in the maternal health sector in the rural areas

Well-trained surgeons and physicians choose to practice their expertise in urban areas leaving workers with less training and education in rural areas. Health experts are also few compared to the patients in need of maternal health care. Failure to access maternal health services of high quality in rural areas is a significant reason for workforce shortages (Hung, P, 2017). This results in premature birth, severe maternal morbidity, or maternal mortality. Because of a lack of workforce, it is crucial to enhance virtual platforms where the providers of maternal services can improve their engagement with pregnant women.

Lack of Affordable Insurance services among the population

Most residents living in rural areas are uninsured compared to patients in metropolitan regions. Rural populations have higher rates of low to moderate incomes and have a low probability of having employer-sponsored health insurance coverage. Financial barriers play an important role in maternal health services. Most families in rural areas have less income and thus cannot manage to pay for medical insurance services (Long et al., 2018). Having less income places pregnant women at the risk of receiving fewer prenatal care services, leading to delivering children with low weight or worse, resulting in the death of the child or the mother. Ensuring funding of rural hospitals by well-wishers and the government can reduce the risk of maternal morbidity for most women who cannot insure themselves. The high poverty levels and increased number of uninsured individuals have resulted in the closure of hospitals, exposing more patients to severe risk of maternal morbidity. Lack of adequate health care has led to innovative solutions by rural communities such as expanding training for maternal health care providers and making maternal health care more affordable by expanding insurance coverage. Indeed uninsured women have a higher probability of experiencing poor outcomes during pregnancy and delivery.

Unavailability of good infrastructure in the rural areas

The level of development in rural areas is usually low. Lack of reliable transportation leads to declined access to health care facilities as no one, especially the private sectors, would establish their hospitals where there are poor road conditions and public transportation is limited. Traveling long distances to acquire medical consultations has led to increased severe maternal morbidity in rural areas (Kozhimannil, K. B, 2019). Traveling while pregnant causes deep vein thrombosis, vagina bleeding, cervical problems, and prior miscarriage if one has complications. The invention of remote monitoring is a great way to overcome long distances. Telemedicine reduces the burden of long-distance travel for perinatal care. Additionally, programs such as the baby scripts diabetes program that monitor pregnant women’s diabetes daily enables health practitioners to monitor the risk of patients with gestational diabetes that threatens the life of the mother and the child. Indeed poor infrastructure, such as poor roads, increases the risk of maternal morbidity but is avoidable through telehealth services.

Racial and Geographic Disparity

Pregnant women living in rural areas, experience significant racial disparity. There are rising cases of unexpected SMM, resulting to unexpected life threatening outcomes. In a research by Luke et al., (2021), maternal health outcomes have worsened over the years. According to Luke et al., (2021), in the past 25 years, the USA, has recorded increased cases of SMM, which result in long and short term consequences to women’s health. Luke et al., (2021), indicates that adverse maternal outcomes are not uniform across the USA, as studies indicate that Native American and Black women experience higher rates of SMM compared to other races. The factor is influenced by the fact that Native and Black Americans live in underserved rural areas. In their research, Luke et al., (2021), found that there were race disparities with Black and Native women experiencing higher SMM rates, while White pregnant women had considerably low rates. Similalry, research by Katon et al. (2021), indicates that in the USA, racial disparities are common, as Black women are three times more likely to die from pregnancy related factors compared to white women. Katon et al. (2021) research indicates that more than 60,000 birthing women experience SMM with significant racial and geographic disparities. Hence, it is crucial for policymakers to address maternal health crisis in relation to racial disparities to lower maternal morbidity in rural areas.

Women living in rural areas experience geographic constraints, including limited health care resources, geographic isolation, and closing hospitals. Pregnant women in rural areas fail to receive high quality prenatal care and have limited access to specialized obstetric care. This indicates that they do not visit prenatal care until when their pregnancy is at an advanced stage. The challenges that limit them from visiting hospitals include lack of resources in hospitals, lack of quality services, and closure of hospitals. Additionally, according to Luke et al. (2021), women in rural areas have challenges in travel distances to providers placing them at risk as they do not get immediate or quick cardiovascular care.

How are diverse cultures addressed?

Black and Native American pregnant and birthing women place low trust in their medical providers and institutions. The reason for low trust is associated with increasing racism determined by class, education, and income. Research by Dagher and Linares (2022), indicates that racism unfairly disadvantages some communities. Mothers from minority populations do not receive adequate care compared to white counterparts. Furthermore, there is little knowledge about diverse populations’ cultures among the health professions. Koten et al., (2021), affirm that lack of racial diversity among the medical professionals and patients result in increased cases of mistreatment and abuse among Black pregnant women. Black pregnant women who are treated by Black medical professionals have greater trust in their providers and adhere to medical advise. Besides, they obtain pregnancy related care needed, thus, experiencing lower issues of infant mortality


There is a need to address the disparities between rural and urban maternal health services. In rural areas, the government and policy makers should make efforts in reducing maternal morbidity by addressing the unique health needs of pregnant women. For instance, there should be a Medicaid policy reform to extend eligibility and cover unlimited number of support services. Medicaid expansion would improve birth outcomes as there would be reduced racial disparities across the nation. Besides, the expansion would ensure all women have access to affordable health care services, improving pregnancy and birth outcomes. Lack of access to maternal health services, which is the case in rural areas, results in adverse maternal outcomes such as severe maternal morbidity and postpartum depression that are preventable through advancement of the maternal services. According to research by Rossen et al. (2022), previous scholars found that between 2007/2015, SMM was 9% higher in rural areas than in urban centers. Similarly, pregnancy related deaths between 2011/2016 was 63% higher in rural areas than in large metropolitan areas. Hence, to combat SMM, it is essential to address women’s health needs before, during, and after the pregnancy by ensuring they have sufficient health coverage and routine checkups.

There should be interventions to ensure there are increased resources in hospitals to cater for prenatal and postnatal care. Pregnant and birthing women should receive adequate and high quality services to lessen the odds of experiencing SMM. Therefore, the government should ensure rural areas health services are fitted with advanced technology services. There should be innovative care delivery models such as telemedicine, remote monitoring and available referral centers to ensure women access health services regardless of their location.


Pregnant women residing in rural areas experience declining access to obstetric services, education, racial and geographic disparity, and inadequate health care facilities and services fostering severe maternal morbidity and mortality during pregnancy and birthing. According to the above research, it is apparently clear that millions of pregnant women residing in rural areas require emergency treatment to save their lives and their unborn or born infants. Indeed, where a person lives should not determine the outcome of the pregnancy. Understanding these realities faced by pregnant women in rural areas would facilitate successful clinical support systems and reformed policies to reduce maternal morbidity. Indeed, ensuring women access medical care during and after pregnancy is the key to eliminating maternal morbidity.


Hansen, A. C., Slavova, S., & O’Brien, J. M. (2022). Rural residency as a risk factor for severe maternal morbidity. The Journal of Rural Health38(1), 161-170. DOI: 10.1111/jrh.12567.

Luke, A. A., Huang, K., Lindley, K. J., Carter, E. B., & Joynt Maddox, K. E. (2021). Severe Maternal Morbidity, Race, and Rurality: Trends Using the National Inpatient Sample, 2012–2017. Journal of Women’s Health30(6), 837-847.

Katon, J.G., Enquobahrie, D.A.,  Jacobsen,K., &  Zephyrin. L. (2021). Policies for Reducing Maternal Morbidity and Mortality and Enhancing Equity in Maternal Health. The Commonwealth Fund.

Rajbanshi, S., Norhayati, M. N., & Nik Hazlina, N. H. (2021). Severe maternal morbidity and its associated factors: A cross-sectional study in Morang district, Nepal. PloS one16(12), e0261033.

Kozhimannil, K. B., Interrante, J. D., Henning-Smith, C., & Admon, L. K. (2019). Rural-urban differences in severe maternal morbidity and mortality in the US, 2007–15. Health Affairs38(12), 2077-2085.

Weitzman, A. (2017). The effects of women’s education on maternal health: Evidence from Peru. Social science & medicine180, 1-9.

Hung, P., Henning-Smith, C. E., Casey, M. M., & Kozhimannil, K. B. (2017). Access to obstetric services in rural counties is still declining, with 9 percent losing services, 2004–14. Health Affairs36(9), 1663-1671.

Long, A. S., Hanlon, A. L., & Pellegrin, K. L. (2018). Socioeconomic variables explain rural disparities in US mortality rates: Implications for rural health research and policy. SSM-Population Health6, 72-74.

Rossen, L. M., Ahrens, K. A., Womack, L. S., Uddin, S. F., & Branum, A. M. (2022). Rural-Urban Differences in Maternal Mortality Trends in the US, 1999-2017: Accounting for the Impact of the Pregnancy Status Checkbox. American Journal of Epidemiology.

Dagher, R. K., & Linares, D. E. (2022). A Critical Review on the Complex Interplay between Social Determinants of Health and Maternal and Infant Mortality. Children9(3), 394.


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