We thank Grzybowski1 and Lespérance2 and their colleagues for their comments on our article3 and strongly agree that local maternity services have beneficial effects on maternal and fetal/infant health in rural areas. These groups have been longstanding champions for rural maternity care services in Canada, and we applaud their efforts to provide quality care for low-risk women in rural settings.4
However, we stand by the results of our study, which showed elevated rates of severe maternal morbidity in women residing in rural versus urban British Columbia. We found that the average adjusted risk for rural women was two-fold higher for some severe morbidity. Some rural subgroups and regions may have lower risk than this average, but other regions would have a higher risk.
Geographic barriers are notoriously difficult to quantify. Although travel distance may be a good indicator of access to care, it varies considerably with weather and road conditions as well as type of transportation. Our study used the degree of rural isolation developed by Statistics Canada that has been used to approximate access to health care services.5,6 We were conservative in our approach and included rural areas with high metropolitan influence (typically considered rural) within the urban category.
Rates of level 2 admission to a neonatal intensive care unit were 3.7% for infants born to women from rural areas and 8.1% for infants born to women in urban areas; rates of level 3 admission were 0.8% and 2.0%, respectively (some infants were admitted to both). This may indicate potential barriers to care in neonatal intensive care units for infants of rural women — a finding that should prompt further study.
We do not agree that our findings undermine the dedicated work of rural maternity care providers in British Columbia, nor would we wish to do so. Rural obstetric care presents challenges that are unlike those encountered in urban settings. Our study found that some morbidity indicators (e.g., transfusion) were not substantially different, which attests to the quality of rural care.
Our study was not designed to determine the factors that influence the risk of adverse outcomes among rural women, and we did not intend to suggest that rural health care providers are responsible. We strongly support the need for further studies and attention to rural obstetric care.
References
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