Rural-Urban Differences in Obstetric Care 2002-2010 and Implications for the Future

Medical Care

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.

University of Minnesota Rural Health Research Center
Katy Kozhimannil, Peiyin Hung, Shailendra Prasad, Michelle Casey, Ira Moscovice