Birth Outcomes Among Older Mothers in Rural Versus Urban Areas: A Residence-Based Approach

Authors

  • Sarka Lisonkova MD, PhD,

    1. Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
    2. Child and Family Research Institute, Vancouver, British Columbia, Canada
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  • Samuel B. Sheps MD, PhD,

    1. School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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  • Patricia A. Janssen PhD,

    1. Child and Family Research Institute, Vancouver, British Columbia, Canada
    2. School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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  • Shoo K. Lee MD, PhD, MBBA,

    1. Department of Paediatrics, University of Toronto, Ontario, Canada
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  • Leanne Dahlgren MD, MPH,

    1. Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
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  • Ying C. MacNab PhD

    1. School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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  • Funding: Western Regional Training Centre for Health Services Research, Canada; Michael Smith Foundation for Health Research, Canada; and Canadian Institutes of Health Research.

  • We would like to thank all people who have contributed to the BC PHP perinatal data collection and management. We also thank Serena Howlett, JD, MPH, for reviewing the manuscript. For further information, contact: Sarka Lisonkova, MD, PhD, Child and Family Research Institute, Children's and Women's Health Centre, E400-4480 Oak St. Vancouver, Canada V6A 3V4; e-mail slisonkova@cfri.ca.

Abstract

Purpose: We examined the association between rural residence and birth outcomes in older mothers, the effect of parity on this association, and the trend in adverse birth outcomes in relation to the distance to the nearest hospital with cesarean-section capacity.

Methods: A population-based retrospective cohort study, including all singleton births to 35+ year-old women in British Columbia (Canada), 1999-2003. We compared birth outcomes in rural versus urban areas, and between 3 distance categories to a hospital (<50, 50-150, >150 km). Outcomes included labor induction, cesarean section, stillbirth, perinatal death, preterm birth (<37 weeks), small-for-gestational-age, large-for-gestational-age, and neonatal intensive care unit admission. We used multivariate regression to obtain adjusted odds ratios (ORs) and 95% confidence intervals (CIs).

Findings: Among the 29,698 subjects, 11.5% lived in rural areas; 5% lived within 50-150 km; and 1.1% lived >150 km from a hospital. Rural women were at lower risk of primary and repeat cesarean section (OR = 0.9, CI: 0.9-1.0; OR = 0.7, CI: 0.6-0.9) and small-for-gestational-age (OR = 0.8, CI: 0.7-0.9) births; they were at increased risk for perinatal death (OR = 1.5, CI: 1.1-2.1) and large-for-gestational-age (OR = 1.1, CI: 1.1-1.2) births. The association was stronger among multiparous versus primiparous women. No differences in emergency cesarean section, preterm birth, or neonatal intensive care admission were found, regardless of parity. Perinatal mortality increased with distance from hospital; OR = 1.5 (CI: 1.1-2.1) per distance category.

Conclusions: Older women in rural versus urban areas had a lower rate of cesarean section and increased risk of perinatal death. The risk of perinatal death increased with the distance to hospital. Further studies need to evaluate the contribution of underlying perinatal risks, access to care, and decision making regarding referral and transport.

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