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• W1996179133 abstract "Rural and urban women vary in health outcomes. In this article, we will explore the observed differences and try to answer the following questions: Is there a difference in rural, suburban, and urban women’s reproductive health? What are these differences? What accounts for these differences? The distinction between rural and urban women is an artificial one in many ways. “Rural” America is as diverse as “urban” America. Rural women vary markedly in different parts of the United States in their ethnicity, their income, their education, and in their access to care. Differences in outcomes between rural and urban women may be masked by differences in rural communities and by differences between different groups of rural women. Much of the existing research has simply focused on urban versus rural areas or metropolitan versus nonmetropolitan areas. This distinction may not be an adequate comparison. Jackson, Wyoming and Frederick, Oklahoma are both rural areas but are as different from each other as Harlem is from Long Island. Rural southeastern America is markedly different from the rural northern Great Plains. An examination of the teen pregnancy rates by state shows that the southern states plus California have the highest teen pregnancy rates, and that northern states have the lowest teen pregnancy rates. The difference in teen pregnancy rates appears to be greater between north and south than between rural and urban. Rural and urban women differ in multiple measures of health outcomes. Death rates vary between rural and urban women, but they also vary among rural areas. Both the lowest and highest death rates occur in predominantly rural areas. Many of the lowest rates are in the rural upper Great Plains, whereas the highest rates are in rural Oklahoma, Arkansas, and Appalachia. The distinction between rural and urban may be an inadequate description of the differences in these women. Several studies have shown that rural women are more likely to deliver a low birth weight infant than urban women. Hulme and Blegen1Hulme P.A. Blegen M.A. Residential status and birth outcomes is the rural/urban distinction adequate?.Public Health Nurs. 1999; 16: 176-181Crossref PubMed Scopus (23) Google Scholar studied 243 rural women who delivered at a tertiary care hospital. Rural women had lower birth weight and more complications than urban or suburban women. Alexy et al2Alexy B. Nichols B. Heverly M.A. Garzon L. Prenatal factors and birth outcomes in the public health service a rural/urban comparison.Res Nurs Health. 1997; 20: 61-70Crossref PubMed Scopus (22) Google Scholar found that rural women (n = 364) had a higher incidence of low birth weight infants than urban women (n = 415) cared for in Public Health Dept Clinics. However, they found that the difference was due to other defined risks and could not be attributed to rural residence. Larson et al3Larson E.H. Hart L.G. Rosenblatt R.A. Rural residence and poor birth outcome in Washington state.J Rural Health. 1992; 8: 162-170Crossref PubMed Scopus (25) Google Scholar studied 5 years of births in Washington State. Rural women had similar rates of low birth weight after controlling for other risk factors. However, rural women delivering in urban hospitals had worse outcomes than rural women delivering in rural locations. Rural women were more likely to receive inadequate prenatal care. Larson et al4Larson E.H. Hart L.G. Rosenblatt R.A. Is non-metropolitan residence a risk factor for poor birth outcome in the U.S.?.Soc Sci Med. 1997; 45: 171-188Crossref PubMed Scopus (61) Google Scholar also studied 11.06 million singleton births in the United States between 1985 and 1987. They found that residence in a nonmetropolitan county was not associated with low birth weight after controlling for other risk factors, but there was a higher rate of postneonatal mortality in rural counties. Chabot et al5Chabot M.J. Garfinkel J. Pratt M.W. Urbanization and differentials in white and nonwhite infant mortality.Pediatrics. 1975; 56: 777-781PubMed Google Scholar studied infant deaths in the United States from 1962 to 1967. They found that after 1 day of life infant mortality increased progressively as degree of urbanization decreased and that fetal death rates increased progressively as degree of urbanization decreased. Clarke et al studied all births in Florida during 1987. They found that rural infants had increased odds of an infant death. From the above cited studies, it appears that rural women may be more likely to deliver a low birth weight infant, but that the increased risk can be attributed to factors other than rural residence. There also appears to be an increased risk of infant death in rural counties. There appear to be several factors that account for the increased risk of delivery of a low birth weight infant. Williamson and LeFevre6Williamson Jr, H.A. LeFevre M. Tangible assistance a simple measure of social support predicts pregnancy outcome.Fam Pract Res J. 1992; 12: 289-295PubMed Google Scholar found that rural women who reported no or one reliable helper in the third trimester had a higher rate of poor outcomes (neonatal death, transfer to neonatal intensive care unit, birth weight <2500 g, or 5-minute Apgar <7) than those with two or more helpers (13.2% versus 5.7%, P = .08). Rural women may be more isolated and have less access to helpers than urban women. Rural women appear to be less likely to receive adequate prenatal care than urban women. Allen and Kamradt7Allen D.I. Kamradt J.M. Relationship of infant mortality to the availability of obstetrical care in Indiana.J Fam Pract. 1991; 33: 609-613PubMed Google Scholar studied adequacy of care in Indiana. There was a negative correlation between physician availability and infant mortality in Indiana’s nonmetropolitan counties (r = −.38, P < .02). Nesbitt et al8Nesbitt T.S. Larson E.H. Rosenblatt R.A. Hart L.G. Access to maternity care in rural Washington its effect on neonatal outcomes and resource use.Am J Public Health. 1997; 87: 85-90Crossref PubMed Scopus (64) Google Scholar studied 29,809 births in Washington State to rural women. They compared areas where less than one third of women left the area for care to those in which more than two thirds left. Poor local access to providers of obstetric care was associated with a significantly greater risk of having a nonnormal neonate. In another study, Nesbitt et al9Nesbitt T.S. Connell F.A. Hart L.G. Rosenblatt R.A. Access to obstetric care in rural areas effect on birth outcomes.Am J Public Health. 1990; 80: 814-818Crossref PubMed Scopus (156) Google Scholar studied 33 rural hospital service areas in Washington State. Women from communities with relatively few obstetric providers in proportion to number of births were less likely to deliver in their local community hospital and had a greater proportion of complicated deliveries, higher rates of prematurity, and higher costs of neonatal care than those from communities with more obstetrical providers. Miller et al10Miller M.K. Clarke L.L. Albrecht S.L. Farmer F.L. The interactive effects of race and ethnicity and mother’s residence on the adequacy of prenatal care.J Rural Health. 1996; 12: 6-18Crossref PubMed Scopus (23) Google Scholar studied data from the National Maternal and Infant Health Survey. Rural women were more likely to receive inadequate prenatal care regardless of race or sociodemographic factors. Mobley et al11Mobley J.A. McKeown R.E. Jackson K.L. Sy F. Parham J.S. Brenner E.R. Risk factors for congenital syphilis in infants of women with syphilis in South Carolina.Am J Public Health. 1998; 88: 597-602Crossref PubMed Scopus (48) Google Scholar found that rural women in South Carolina were twice as likely to have an infant with congenital syphilis and were less likely to receive adequate prenatal care. From these studies, it can be concluded that rural women have less access to prenatal care and are less likely to receive adequate prenatal care. Lack of access to prenatal care is associated with increased risk of delivery of a low birth weight infant and increased risk of neonatal and infant death. Sieck12Sieck C.C. Vaginal birth after cesarean section a comparison of rural and metropolitan rates in Oklahoma.J Okla State Med Assoc. 1997; 90: 444-449PubMed Google Scholar studied cesarean sections and vaginal birth after cesarean section (VBAC) in rural and urban hospitals in Oklahoma from 1993 to 1996. The rate of cesarean section was higher in rural (31%) than urban (18%) hospitals. Also, the rate of attempted VBAC (46%) and successful VBAC (36%) was higher in urban hospitals than in rural hospitals (30% and 18%, respectively). Safe trial of labor after a cesarean section requires the availability of anesthesia and personnel for emergency cesarean delivery. In many rural areas it is difficult or impossible to meet the standard of care for VBAC. Some rural hospitals and Indian Health Service sites have stopped offering VBAC secondary to inability to meet these standards. Rural women have less access to family planning services than urban women. Henshaw and Van Vorr13Henshaw SK, Van Vort J. Abortion services in the United States, 1991 and 1992. Fam Plann Perspect 1994;26:100–6, 112.Google Scholar reported that most U.S. counties (84%) have no known abortion provider, and in nonmetropolitan areas 94% of counties have no provider. Bennett et al14Bennett T, Skatrud JD, Guild P, Loda F, Klerman LV. Rural adolescent pregnancy: a view from the South. [published errata appear in Fam Plann Perspect 1998 Jan–Feb;30(1):18 and 1998 Mar–Apr;30(2):104] Fam Plann Perspect 1997;29:256–60, 267.Google Scholar studied 1990 census and vital statistics data for eight Southeastern states and found that the teenage birthrate generally was higher in rural than in metropolitan areas. Abortion rates were much lower for rural teenagers than for urban teenagers, regardless of race. Rural women have been effectively denied the right to choose by lack of access to abortion providers. Rural women are at risk for substance abuse, but the pattern of substance abuse may be different.15Buchi K.F. Varner M.W. Chase R.A. The prevalence of substance abuse among pregnant women in Utah.Obstet Gynecol. 1993; 81: 239-242PubMed Google Scholar, 16Cobb P. Hartmann K. Thorp Jr, J.M. Renz C. Stanford D. Rounds K. Perinatal substance abuse within central North Carolina. A suburban-rural perspective.N C Med J. 1997; 58: 36-38PubMed Google Scholar, 17Curtis K.M. Savitz D.A. Arbuckle T.E. Effects of cigarette smoking, caffeine consumption, and alcohol intake on fecundability.Am J Epidemiol. 1997; 146: 32-41Crossref PubMed Scopus (204) Google Scholar, 18Ettlinger T. In harm’s way recognizing and addressing alcohol risk for rural disadvantaged pregnant mothers.Public Health Nurs. 2000; 17: 207-210Crossref PubMed Scopus (4) Google Scholar, 19Eyler F.D. Behnke M. Conlon M. Woods N.S. Wobie K. Birth outcome from a prospective, matched study of prenatal crack/cocaine use II. Interactive and dose effects on neurobehavioral assessment.Pediatrics. 1998; 101: 237-241Crossref PubMed Scopus (98) Google Scholar, 20Eyler F.D. Behnke M. Conlon M. Woods N.S. Wobie K. Birth outcome from a prospective, matched study of prenatal crack/cocaine use I. Interactive and dose effects on health and growth.Pediatrics. 1998; 101: 229-237Crossref PubMed Scopus (107) Google Scholar, 21Fox S.H. Koepsell T.D. Daling J.R. Birth weight and smoking during pregnancy—effect modification by maternal age.Am J Epidemiol. 1994; 139: 1008-1015Crossref PubMed Scopus (65) Google Scholar, 22Kruse J. Le Fevre M. Zweig S. Changes in smoking and alcohol consumption during pregnancy a population-based study in a rural area.Obstet Gynecol. 1986; 67: 627-632Crossref PubMed Scopus (39) Google Scholar, 23Sloan L.B. Gay J.W. Snyder S.W. Bales W.R. Substance abuse during pregnancy in a rural population.Obstet Gynecol. 1992; 79: 245-248PubMed Google Scholar, 24Yawn B.P. Yawn R.A. Uden D.L. Substance use in rural Midwestern pregnant women.Arch Fam Med. 1992; 1 ([see comments]): 83-88Crossref PubMed Scopus (8) Google Scholar Tobacco and marijuana use appears to be more prevalent in rural women, but use of alcohol, cocaine, and other drugs is prevalent in some rural areas. Rural women appear to be at increased risk for adverse pregnancy outcome. This increased risk is explained by other associated risks including inadequate access to care, poverty, race, and substance abuse. Programs for pregnant rural women should focus on increasing access to prenatal care and removing barriers to obtaining care. Geographic barriers pose difficult problems in many areas." @default.
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• W1996179133 title "Panel 3: rural diversity—focus on reproductive issues" @default.
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