Approximately 15% of the 4 million annual U.S. births
occur in rural hospitals.
To (1) measure differences in obstetric care in rural and
urban hospitals, and to (2) examine whether trends over
time differ by rural-urban hospital location.
Research design and subjects:
This was a retrospective analysis of hospital discharge
records for all births in the 2002-2010 Nationwide
Inpatient Sample, which constitutes 20% sample of U.S.
hospitals (N = 7,188,972 births: 6,316,743 in urban
hospitals, 837,772 in rural hospitals).
Rates of low-risk cesarean (full-term, singleton, vertex
pregnancies; no prior cesarean), vaginal birth after
cesarean (VBAC), nonindicated cesarean, and nonindicated
labor induction were estimated.
In 2010, low-risk cesarean rates in rural and urban
hospitals were 15.5% and 16.1%, respectively, and
nonindicated cesarean rates were 16.9% and 17.8%,
respectively. VBAC rates were 5.0% in rural and 10.0% in
urban hospitals in 2010. Between 2002 and 2010, rates of
low-risk cesarean and nonindicated cesarean increased,
and VBAC rates decreased in both rural and urban
hospitals. Nonindicated labor induction was less frequent
in rural versus urban hospitals in 2002 [adjusted odds
ratio = 0.79 (0.78-0.81)], but increased more rapidly in
rural hospitals from 2002 to 2010 [adjusted odds ratio =
1.05 (1.05-1.06)]. In 2010, 16.5% of rural births were
induced without indication (12.0% of urban births).
From 2002 to 2010, cesarean rates rose and VBAC rates
fell in both rural and urban hospitals. Nonindicated
labor induction rates rose disproportionately faster in
rural versus urban settings. Tailored clinical and policy
tools are required to address differences between rural
and urban hospitals.