Developing Rural-Relevant Strategies to Reduce Maternal Morbidity

Research center:
Lead researcher:
Project funded:
September 2018
Project completed:
November 2019

Most people enter pregnancy without anticipating major risks to their health. Yet every year, at least 50,000 experience potentially life-threatening complications of childbirth (e.g., blood clots, acute renal failure, shock, cardiac arrest, respiratory distress, amniotic fluid embolism, eclampsia, complications of anesthesia). The rate of severe maternal morbidity doubled between 1998 and 2011, as did maternal mortality, doubling between 1990 and 2013. In the general population, there were divergent morbidity trends in rural and urban areas, leading to excess mortality among rural residents. Both of these troubling trends rendered residents of rural areas particularly vulnerable to illness and death following childbirth.

Several national clinical efforts were underway to address severe maternal morbidity, but many national efforts did not address the specific conditions of care provided in rural contexts (e.g., limited access to specialty providers, lack of a dedicated operating room for obstetrics, use of general - vs. specialized - nursing staff in labor and delivery units). Attention to the particular challenges faced by rural patients and healthcare facilities was crucial to the success of efforts to reduce maternal morbidity and mortality in rural areas. Additionally, state and federal legislators have increasingly proposed and adopted policies in the wake of rising rates of maternal morbidity and mortality. Many policy efforts focused on the establishment of committees to review cases of maternal morbidity or mortality, and clinical leaders have argued for the importance of these efforts at federal, state, and local levels. As these efforts gained strength, it was not clear to what extent rural populations were recognized and explicitly included in policies designed to address this growing crisis. No prior studies had examined rural-urban differences in current trends in maternal morbidity. Such evidence was urgently needed to inform geographically-tailored clinical and policy efforts to reverse the rising rates of maternal morbidity and mortality nationally.

This project was national in scope and had relevance for policy making at the federal, state, local, and institutional levels. We conducted analyses using both a 20% sample of births (2004-2014) to assess trends and on a 100% sample of hospital-based 2014 births that occurred in 9 states across the four U.S. census regions. We also conducted a review of state and federal legislation (including proposed legislation) related to maternal mortality and maternal morbidity review committees, as well as visited a site at a rural hospital providing obstetric services. The purpose of the visit was to discuss management of care during pregnancy and childbirth with clinicians and hospital administrators; how a high-risk designation affects care for rural residents (e.g., referrals to specialized or subspecialized care); and how decisions are made to transfer rural patients in the intrapartum period.


  • Providing Maternity Care in a Rural Northern Iowa Community
    University of Minnesota Rural Health Research Center
    Date: 08/2020
    This case study highlights how one rural hospital in northern Iowa has successfully sustained a maternity care practice and identifies opportunities for other rural hospitals and communities seeking to ensure local access to care for pregnancy and childbirth.
  • Rural Focus and Representation in State Maternal Mortality Review Committees: Review of Policy and Legislation
    Journal Article
    University of Minnesota Rural Health Research Center
    Date: 08/2019
    Between 1990 and 2013, maternal mortality nearly doubled in the U.S., and rural residents experienced decreasing access to obstetric care. To improve maternal health, many states have established maternal mortality and morbidity review committees (MMRCs). We assessed the extent of rural representation in state policy efforts related to MMRCs.
  • Rural-Urban Differences in Severe Maternal Morbidity and Mortality in the U.S., 2007-15
    Journal Article
    University of Minnesota Rural Health Research Center
    Date: 12/2019
    In the U.S., severe maternal morbidity and mortality (SMMM) is climbing—a reality that is especially challenging for rural communities, which face declining access to obstetric services. Using data for 2007-15 from the National Inpatient Sample, we analyzed SMMM during childbirth hospitalizations among rural and urban residents.
  • Severe Maternal Morbidity and Hospital Transfer Among Rural Residents
    Policy Brief
    University of Minnesota Rural Health Research Center
    Date: 11/2019
    In this brief, we compare hospital transfer rates for rural and urban residents who gave birth. We also provide descriptive information about the relationship between transfer status and severe maternal morbidity and mortality for rural residents nationally who gave birth 2008-2014.