Outcomes for community birth in the rural setting: implications for families and policymakers

Outcomes for rural families giving birth in the community setting were explored in a new article recently released in the peer-reviewed journal, Birth. The article, entitled Rural community birth: Maternal and neonatal outcomes for planned community births among rural women in the United States, 2004-2009 and authored by Elizabeth Nethery MSc, MSM, Wendy Gordon LM, CPM, MPH, Marit L. Bovbjerg PhD, and Melissa Cheyney PhD, CPM, is particularly relevant given the unique challenges created by the rural maternal health care shortage.

Senior author Melissa Cheyney PhD, CPM, discusses her thoughts on the implications of this research for rural families in this recent interview with Jeanette McCulloch, MANA’s Director of Communications:

Jeanette: Let’s start by summing up the findings of the article.

Missy: This study, which used the MANA stats 2.0 dataset, examined outcomes for rural birthing families compared to those that live in areas considered to be non-rural.

What we found is that community births – planned home and birth center births – are as safe for women and their babies in rural communities as in non-rural areas of the country.

For example, the rate of cesarean delivery was 4.7% and not elevated by rural status.

Jeanette: Can you tell us a little bit about why these findings might be surprising?

Missy: Because there are greater distances to emergency care for rural families, we went into the study expecting that there might be worse outcomes among rural women, simply due to length of travel time when the need for a higher level of care arises.

However, once we controlled for risk levels and other confounders, there were no significant differences between rural and non-rural clients’ outcomes or their babies’ outcomes.  

Jeanette: In many states expectant families are facing a rural maternal health care crisis. Can you tell us a little bit about what’s happening there?

Missy: Rural women are often underserved and typically face more barriers than non-rural pregnant people in accessing care. Reasons can include rural hospital closures, shortages of qualified childbirth providers in their area, and long travel distances to receive care. Low-income women who live in rural communities often have unreliable transportation, including gaps in public transit. About 80% of rural counties in the United States have no hospital providing obstetric services, and about 50% of rural counties have no actively practicing obstetric physician. Combined, these factors make it very difficult for many women living in rural communities to establish regular obstetric care. Given maternity care shortages, we tend to think about rural women as facing more challenges and having fewer supports, and as a result, experiencing worse outcomes than non-rural women.

Rural locality can also be compounded by other social factors related to education, ethnicity, socio-economic status and class that can further disenfranchise or marginalize pregnant people living further from urban or suburban maternity care centers. So in addition to having reduced access to care, a higher percentage of families in rural settings may be at risk due to multiple social and clinical factors. Reduced access to care within communities with more medically- and socially-complex pregnancies is not an ideal combination.

Jeanette: What are the takeaways for rural families who don’t have optimal access to hospital care and are looking for birth options?

Missy: We know the benefits of early and regular prenatal care, but the barriers we’ve described can lead rural women to initiate care later in pregnancy. One way to increase the likelihood of earlier visits for those who are pregnant living in an underserved community is to initiate care with a home birth midwife in your community.

Home birth midwives may live closer or be willing to come to you. This can help solve the problems of travel time and lack of reliable transportation. 

At the outset of pregnancy, we often do not know precisely how the pregnancy is going to unfold. Choice of birth setting and prenatal care provider are not one-time decisions that you make at the beginning of pregnancy, never to revisit. These decisions are made multiple times, together with your midwife as you learn about the health of the pregnancy. Women may begin care with a community midwife and find out some time during the pregnancy about a complication, like high blood pressure or gestational diabetes.

At that point, you can continue your prenatal visits with your midwife, but additionally use the connections your midwife has to access other providers as needed for what we call “co-care” or collaborative care provided by a care team. The additional provider/s bring access to a skill set that may be necessary for supporting a more medically complicated pregnancy. The point is that if a woman cannot access adequate care during her pregnancy, she cannot be supported and evaluated in a way that helps ensure a positive outcome. Far too many women in the US show up in the emergency room in labor never having received comprehensive and supportive care during their pregnancy. I believe community midwives can be an important part of changing that.

While many pregnant people will go into labor planning a midwife-attended home or birth center birth in their community, comprehensive prenatal care can help identify instances where you may be better served by having your midwife attend you at the hospital along with additional providers.

You can imagine this scenario for rural families: let’s say they travel an hour to get to obstetric care. After the birth is over, they go back home. They’re now quite isolated from their provider, and they have a new baby at home. One of the benefits of home and birth center birth care is that often there is some kind of in-home postpartum care provided. Following birth, regardless of the location, the midwife can then resume in-home care, providing vital services like breastfeeding support and assessment for postpartum mood disorders and neonatal weight gain and development, all of which are critical but more challenging to access in rural communities.

I think part of what keeps people from considering all of their options when they become pregnant is what anthropologists in our country have called the home/hospital divide. The birth setting debate is an often a contentious one, and so we may fail to see the places we can work together.

The question should not be, at least not initially, about the most appropriate location for birth as that may not be something a family can know until the pregnancy unfolds. It is more important to initiate care early with a provider who can respect and support families through the many decisions they will make over the course of care. But for women to have no or limited prenatal care because of distance to travel or the lack of reliable transportation is both unacceptable and unnecessary given the growing presence of community midwives. Can we begin to think about midwives as extending maternity care in their community—working autonomously under some circumstances and as part of a larger care team when that is indicated?

Jeanette: What are the takeaways for healthcare advocates and for policy makers?

Missy: Health care advocates and policy makers can improve infant and maternal outcomes overall by thinking more broadly about the childbearing year. We need to move away from our focus on the 6 to 36 hours that the average person is going to be in labor and giving birth, and realize that wellbeing is also dependent on what is done before the onset of labor and following the birth. We can rely on community-based midwives to provide in-home care even when someone develops significant risk factors and ends up feeling safest in the hospital. Midwives can and should be used prenatally and in the postpartum period to provide additional services to underserved communities. Because much of the debate about home or birth center versus hospital has centered so closely on the moment of birth and the safety of the newborn, we have lost the opportunity to discuss more broadly the totality of care that we know is needed to support healthy pregnancies and healthy families. The findings from the article suggest some new opportunities for dialog around how we can improve maternity services among underserved rural communities.