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. Author manuscript; available in PMC: 2024 Jan 1.
Published in final edited form as: J Obstet Gynecol Neonatal Nurs. 2022 Nov 15;52(1):36–49. doi: 10.1016/j.jogn.2022.10.001

Racial Disparities in Respectful Maternity Care During Pregnancy and Birth After Cesarean in Rural United States

Bridget Basile Ibrahim 1, Katy Backes Kozhimannil 2
PMCID: PMC9839498  NIHMSID: NIHMS1848697  PMID: 36400125

Abstract

Objective:

To describe the experiences of pregnancy and birth after cesarean of women who live in rural areas of the United States, including access to vaginal birth after cesarean (VBAC), type of maternity care provider, travel times, autonomy in decision-making, and respectful maternity care.

Design:

Retrospective observational study.

Setting:

Online questionnaire of women who gave birth in the United States.

Participants:

Women (N = 1711) with histories of cesarean and subsequent births within 5 years of participating.

Methods:

We calculated descriptive and bivariate statistics by identified areas of residence and stratified measures of autonomy and respectful maternity care by self-identification as member of a racialized group. We applied qualitative descriptive analysis to responses to an open-ended survey question.

Results:

Two hundred ninety-nine (17.5%) participants identified their areas of residence as rural. Similar percentages of rural and metropolitan participants were able to plan VBAC (p =.88). More rural participants than metropolitan participants reported travel times of more than 60 minutes to give birth (p <. 001), and fewer had obstetricians (p = .002) or doulas (p = .03). Rural participants from racialized groups experienced significantly less respectful maternity care than White, non-Hispanic rural participants and all metropolitan participants (p = .04). Qualitative data illustrating the main findings are included.

Conclusions:

Our findings highlight challenges faced by rural residents accessing VBAC and help to explain why rates of VBAC in rural areas remain low. We suggest a range of clinical and policy strategies to improve access to VBAC in rural areas and to improve the quality of maternity care for racialized women who live in rural areas.

Keywords: rural, health equity, vaginal birth after cesarean, maternal health, respectful maternity care, patient experience, patient and family-centered care

Precis

Women who lived in rural areas and identified as members of racialized groups experienced disrespectful maternity care more than their White, non-Hispanic counterparts

Across the United States, more than 500,000 infants are born to people who live in rural communities each year (March of Dimes, 2022). Compared to those who live in urban areas, rural residents have higher rates of severe maternal morbidity and mortality (Kozhimannil et al., 2019) and infant mortality (Beal, 2021; Ely et al., 2014). They also are less likely to give birth in hospitals with NICUs (Kozhimannil, Hung, et al., 2016). Black and Indigenous women who live in rural areas are at even greater risk for severe maternal morbidity and mortality and infant mortality than White women who live in rural areas and are more likely to have inadequate access to prenatal care and other evidence-based support for maternal and infant health (Baldwin et al., 2002; Basile Ibrahim, Interrante, et al., 2022; Basile Ibrahim, Tuttle, et al., 2022; Kozhimannil, Interrante, Tofte, et al., 2020; Singh, 2021). Further, Indigenous women who live in rural areas more frequently lack access to obstetric critical care (Kroelinger et al., 2020).

In light of these significant health inequities based in race and place, the U.S. Surgeon General (Adams & U.S. Department of Health and Human Services, 2020) and the U.S. Department of Health and Human Services (2020) set a national goal of decreasing racial disparities related to maternal morbidity and mortality, and the Centers for Medicare and Medicaid Services (2019) made improving access to maternal health care in rural communities a priority.

Cesarean birth is sometimes medically indicated, but judicious use is needed because of the associated risks and sequelae of surgical birth, including increased risk for maternal death, infection, and abnormal placentation in subsequent pregnancies (Keag et al., 2018; Mascarello et al., 2017). One approach to improve rates of maternal morbidity and mortality is to increase rates of vaginal birth relative to cesarean birth for pregnancies in which vaginal birth is not contraindicated (American College of Obstetricians and Gynecologists, 2019; Sabol et al., 2015). Although vaginal birth after cesarean (VBAC) is considered a safe, cost-effective option for most women with histories of one or two cesareans (American College of Nurse-Midwives; American College of Obstetricians and Gynecologists, 2019; Guise et al., 2010), rates of VBAC have remained low (<15% of pregnant women with histories of cesarean annually) across the United States since the early 2000s (Martin et al., 2019). The rate of VBAC in the United States was 13.9% in 2020 (Osterman et al., 2022), and rates of VBAC were significantly higher in urban hospitals than in rural hospitals from 1997 to 2021 (Kozhimannil et al., 2014; Sieck, 1997; Wendling et al., 2021). Recent data show that less than half (38%) of rural hospitals with obstetric services routinely offer VBAC (Heinrich et al., 2016). The lack of access to VBAC in rural hospitals may be associated with the capacity to immediately provide for a cesarean if one is needed, which varies markedly types of communities (100% urban, 88% suburban, and 76% rural; Korst et al., 2011). Researchers found that women who lived in rural areas, as determined by a residence county population of less than 100,000, were 23% to 44% less likely to have a VBAC compared with women who lived in counties with populations greater than 100,000 (Basile Ibrahim, Kennedy, & Holland, 2020), and giving birth in a rural hospital was associated with a lower likelihood of VBAC than giving birth in an urban hospital (Guise et al., 2010).

With limited local access to VBAC, some women in rural areas have no option other than to undergo repeat cesareans (Cox et al., 2015) or they may feel forced to make higher-risk decisions for childbirth. These decisions include laboring at home until very late in labor to avoid cesarean at a hospital that does not offer VBAC (Basile Ibrahim, Kennedy, & Whittemore, 2020); free birthing without the assistance of a trained birth provider (Diamond-Brown, 2020); bypassing local hospitals to access more distant hospital-based care; or choosing homebirth after cesarean, which for patients without histories of vaginal birth can have less optimal outcomes than hospital-based VBAC (Bovbjerg et al., 2017; Cheyney et al., 2014; Cox et al., 2015). All of these options involve potential health risks to the woman and newborn that could be avoided if access to hospital-based VBAC was more readily available in rural areas.

To improve access to high-quality, evidence-based options for maternal health care for women who live in rural areas, it is essential to first document the experiences of these women who sought VBAC. In this retrospective, observational study, we describe the experiences of pregnancy and birth after cesarean of women who live in rural areas of the United States, including access to VBAC, type of maternity care provider, travel times, autonomy in decision-making, and respectful maternity care. We compare these experiences with those of women who live in metropolitan areas. We further stratify experiences of autonomy in decision-making and respectful maternity care by self-identification as a member of a racialized community (i.e., self-identifying as any race/ethnicity other than White, non-Hispanic). Finally, we augment our quantitative findings with qualitative data.

Methods

Design

We report a subset of data collected from a broader mixed methods study of experiences of pregnancy and birth after cesarean in the United States. The study’s methods and primary mixed methods findings were previously described in detail (Basile Ibrahim, Knobf, et al., 2020). We obtained Institutional Board Approval for this study (Yale University Institutional Review Board protocol # 2000021384).

Setting and Participants

We recruited women through pregnancy and birth peer support networks on social media (Improving Birth, n.d.; International Cesarean Awareness Network, n.d.). Eligible participants were English-speaking adults (≥18 years of age) with histories of cesarean who subsequently gave birth in the United States within the preceding 5 years. Because we sought a breadth of experiences, we did not use participants’ knowledge of their uterine incision type or mode of subsequent birth as exclusion criteria. Although we refer to our participants as women, we did not query gender identity in our questionnaire, and therefore we are unable to accurately describe the gender identities of our participants. We acknowledge that our participants may not all identify as women and likely had a variety of gender identities.

Measures

We collected data via a web-based questionnaire from May through October 2018. The questionnaire included a birth history form; the Mother’s Autonomy in Decision Making scale (MADM), which is used to measure autonomy in decision-making for maternity care (Vedam, Stoll, Martin, et al., 2017); and the Mothers on Respect Index (MORi), which is used to measure experiences of respectful maternity care (Vedam, Stoll, Rubashkin, et al., 2017). Both measures were developed using a community-based participatory process, validated with populations in the United States, and displayed high reliability and internal consistency. The MADM Cronbach’s alpha was reported as 0.96 (Vedam, Stoll, Martin, et al., 2017) and the MORi Cronbach’s alpha was reported as 0.94 (Vedam, Stoll, Rubashkin, et al., 2017). On the seven-item MADM scale, participants rate their ability to state their preferences in decision-making, whether different care options were presented, and if they felt their choices were respected during their decision-making for maternity care; possible scores range from 7 to 42. On the 14-item MORi, participants describe their level of comfort in their maternity care interactions with their providers and the related decision-making processes; possible scores range from 14 to 84. Higher scores on each scale indicate greater autonomy in decision-making and respect when interacting with providers during pregnancy and birth. A researcher-developed, open-ended item was included in the questionnaire: “Please use this space to share anything you feel is unique, interesting, or notable about your pregnancy and birth experiences.”

Participants identified their areas of residence as rural, suburban, or urban on a questionnaire item based on their own definition and assessment of their place of residence. We combined suburban and urban areas into a “metropolitan” category for comparison with rural residents in this analysis. Participants were able to select from a list of adversities experienced since the birth of their first child, with instructions to check all that apply. Table 1 and Table 2 report other demographic, prenatal, and birth variables (e.g., age, region of residence, level of education, employment status, marital status, annual household income, parity, race, ethnicity, country of birth, religious affiliation, access to VBAC, provider type, insurance status, use of a doula, travel times) derived from responses to items on the questionnaire, which is included as Supplementary Table S1.

Table 1.

Birth and demographic characteristics of participants of rural and metropolitan areas with a history of cesarean birth, United States, 2018

Characteristic All participants N = 1711 (100) Rural participants n = 299 (17.5) Metropolitan participants n = 1412 (82.5) p value
M SD M SD M SD
Maternal Age (years) 34 4.51 33 4.96 34 4.47 <.0001*
n (%) n (%) n (%)
Region of residence a <.0001*
 Northeast 194 (11.3) 44 (14.7) 150 (10.6)
 South 729 (42.6) 122 (40.8) 607 (43.0)
 Midwest 421 (24.6) 95 (31.8) 326 (23.1)
 West 367 (21.4) 38 (12.7) 329 (23.3)
Highest level of education completed <.0001*
 No high school diploma 13 (0.8) 3 (1.0) 10 (.01)
 High school diploma/ GED 106 (6.2) 32 (10.7) 74 (5.2)
 Some college/ 2-year degree 515 (30.1) 123 (30.8) 392 (27.8)
 4-year degree 649 (37.9) 96 (32.1) 553 (39.2)
 Postgraduate degree 428 (25.1) 45 (15.1) 383 (27.1)
Paid work at time of birth 950 (55.5) 155 (51.8) 795 (56.3) .16
Married/cohabiting 1672 (97.7) 287 (96.0) 1385 (98.1) .07
Annual household income (USD) <.0001*
 Less than $20,000 75 (4.4) 29 (9.7) 46 (3.3)
 $20,000-$50,000 474 (27.9) 118 (39.5) 356 (25.2)
 $50,000-$80,000 468 (27.5) 88 (29.4) 380 (26.9)
 $80,000-$125,000 441 (25.9) 46 (15.4) 395 (28.0)
 More than $125,000 244 (14.3) 18(6.02) 226 (16.0)
Parity .17
 2 950 (55.5) 146 (48.8) 804 (56.9)
 3 463 (27.1) 89 (29.8) 374 (26.5)
 4 182 (10.6) 40 (13.4) 142 (10.1)
 5+ 116 (6.8) 24 (8.0) 92 (6.5)
Race .13
 American Indian/ Alaska Native 18 (1.1) 7 (2.35) 11 (.01)
 Asian 22 (1.3) 3 (1.0) 19 (1.3)
 Black 31 (1.9) 3 (1.0) 28 (2.0)
 Multiracial 38 (2.2) 4 (1.3) 34 (2.4)
 Other or Native Hawaiian/Pacific 30 (1.8) 0 (0) 30 (2.1)
Islander
 White 1568 (91.9) 278 (93.29) 1290 (91.4)
Latinx or Hispanic ethnicity 105 (6.1) 13 (4.4) 92 (6.5) .15
United States born 1638 (95.7) 289 (96.7) 1349 (95.5) .38
Practice an organized religion 923 (54.0) 177 (59.4) 746 (52.8) .04*
Adversities since birth of first child b
 Not able to buy enough food 158 (9.2) 31 (10.3) 127 (9.0)
 Lack of health insurance 301 (17.6) 82 (27.4) 219 (15.5)
 Heat or electricity turned off 68 (4.0) 20 (6.7) 48 (3.4)
 Not able to meet financial obligations 272 (15.9) 57 (19.1) 215 (15.2)
 Not able to find work 117 (6.8) 24 (8.0) 93 (6.6)
 Child protective services involvement 35 (2.0) 9 (3.0) 26 (1.8)
 Housing instability 91 (5.3) 24 (8.0) 67 (4.7)
 Problems with drug/ alcohol dependency 10 (0.6) 2 (0.7) 8 (.01)
 Imprisonment of self or partner 12 (0.7) 2 (0.7) 10 (.01)
 Intimate partner violence 50 (2.9) 9 (3.0) 41 (2.9)
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Note: M = mean; SD = standard deviation

a

Region of residence: Northeast (CT, MA, ME, NH, NJ, NY, PA, RI, VT), South (AL, AR, DC, DE, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX,VA, WV), Midwest (IA, IL, IN, KS, MI, MN, MO, ND, NE, OH, SD, WI), West (AK, AZ, CA, CO, HI, ID, MT, NM, NV, OR, UT, WA, WY).

b

Each participant could report more than one answer for this question that had instruction to check all that apply

*

p < 0.05

Table 2.

Descriptive Statistics for Prenatal and Birth Variables by Residency, United States, 2018

Birth characteristic All participants

N=1711(100)		 Rural participants n (%)
n=299 (17.5)		 Metropolitan participants n (%)

n=1412 (82.5)
p value
Year of most recent birth (mode) 2017 2017 2017 .34
Knew VBAC was an option 1657 (96.8) 289 (96.7) 1368 (96.9) .84
Desired a VBAC 1628 (95.1) 288 (96.3) 1340 (94.9) .29
Plan/attempt a VBAC 1498 (87.6) 261 (87.3) 1237 (87.6) .88
Had a VBAC 1107 (64.7) 199 (66.6) 908 (64.3) .45
Provider for 1st pregnancy .0001*
 Certified Nurse Midwife 333 (19.5) 61 (20.4) 272 (19.3)
 Family Doctor 52 (3.0) 21 (7.0) 31 (2.2)
 Obstetrician 1246 (72.9) 203 (67.9) 1043 (73.9)
 Other Midwife 74 (4.3) 12 (4.0) 62 (4.4)
 Other 4 (0.2) 1 (0.33) 3 (.01)
 None 1 (0.1) 1 (0.33) 0 (0)
Provider for 2nd pregnancy .002*
 Certified Nurse Midwife 462 (27.0) 72 (24.1) 390 (27.6)
 Family Doctor 36 (2.1) 13 (4.4) 23 (1.6)
 Obstetrician 1053 (61.6) 178 (59.5) 875 (62.0)
 Other Midwife 142 (8.3) 29 (9.7) 113 (8.0)
 Other 9 (0.5) 4 (1.34) 5 (.01)
 None 7 (0.4) 3 (1.0) 4 (.01)
Insurance for 2nd pregnancy & birth <.0001*
 Private 1270 (74.2) 174 (58.2) 1096 (77.6)
 Medicaid /other government insurance 359 (21.0) 96 (32.1) 263 (18.6)
 Other 51 (3.0) 15 (5.0) 36 (2.5)
 No insurance 31 (1.8) 14 (4.7) 17 (1.2)
Doula care for 2nd birth 669 (39.1) 101 (33.8) 568 (40.2) .03*
Travel time from home to 2nd birth location <.0001*
 Less than 30 minutes 1145 (67.0) 134(44.8) 1011 (71.6)
 30-60 minutes 447 (26.2) 107(35.8) 340 (24.1)
 > 60 minutes 116(6.8) 58(19.4) 58 (4.1)
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*

p < 0.05

Quantitative Analysis

We calculated descriptive statistics for the entire sample and stratified them by area of residence. Bivariate statistics (chi-square tests for categorical variables and t-tests and ANOVA for continuous variables) were computed to assess differences between rural versus metropolitan residence and experiences of access to VBAC, type of maternity care provider, and scores on the MADM scale and MORi. We used a significance level of 0.05 for all statistical tests. Statistical analyses were completed using SAS Version 9.4 for Windows (Cary, NC). This analysis presents descriptive analyses, so no confounding variables are included. The dataset for analysis was created with all participants who had complete data for key variables including location of residence, mode of subsequent birth, and MADM and MORi scores. Respondents with missing data for descriptive variables were excluded in analyses, per SAS defaults (Missing Data in SAS, SAS Learning Modules, n.d.).

To explore associations between identification with dominant versus non-dominant group (Beatty Moody et al., 2021), we created a racial identification variable by dichotomizing participants who identified as a race or ethnicity that has been traditionally non-dominant, i.e., that has been historically or is currently marginalized within the United States (those participants who identified as any race/ethnicity other than White, non-Hispanic) into a “racialized” category that includes Black Persons, Indigenous Persons, Hispanic Persons, and other Persons of Color (The Homeless Hub, 2021). We grouped those who self-identified as White, non-Hispanic in the “White, non-Hispanic” category. In many communities, people from racialized groups are not a minority of the overall population; therefore, we opted to use the term “racialized” rather than the more traditional term “minority” (The Homeless Hub, 2021). We computed bivariate statistics to determine differences in scores of measures of respect and autonomy in maternity care as reported by the two groups.

Qualitative Analysis

We analyzed qualitative data from an open-ended survey question using qualitative descriptive analysis (Doyle et al., 2020) to describe common themes identified across the experiences of rural participants. Qualitative data supplied by rural participants was identified and pulled from the larger dataset, inductive codes were applied by two individuals with expertise in qualitative methods, and rural-specific themes were identified (Doyle et al., 2020). Illustrative quotes provide depth of explanation of the quantitative results and serve to further highlight the experiences of the rural women who sought VBAC.

Results

Of the 1711 participants from all 50 states who completed the questionnaire, 299 (17.5%) indicated that they lived in rural communities. As shown in Table 1, the mean age of participants from rural areas was 33 years. Thirty-one rural participants self-identified as a member of a racialized group, which represented 10.4% of participants from rural areas. Rural participants were more likely to be high school graduates and less likely to hold graduate degrees than metropolitan participants (p < 0.001). Participants from rural areas more frequently reported one or more life adversities since becoming parents than metropolitan residents (e.g., being unable to meet financial obligations, being unable to buy enough food, having their heat or electricity turned off, being unable to find work, lacking health insurance, housing instability, intimate partner violence, involvement of child protective services, incarceration of self or partner, and problems with drug/alcohol dependency). Medicaid was the primary type of health insurance for 32.1% of rural participants compared to 18.6% of metropolitan participants (p < .0001).

As shown in Table 2, participants from rural and metropolitan areas expressed a nearly universal preference for VBAC, and most were able to plan or attempt a VBAC. Ultimately, 199 (66.6%) rural participants had VBACs, as did a similar proportion of their metropolitan counterparts. More rural participants had family doctors as their maternity care providers (4.4% vs 1.9%), and fewer had obstetricians (61.9% vs 64.6%) compared with metropolitan participants (p=.002). Fewer rural participants had a dedicated birth support person or doula for their most recent birth than metropolitan participants (33.8% vs 40.2%, p=.03). Regarding travel time to give birth, 19.4% of rural participants travelled more than 60 minutes vs 4% of metropolitan residents (p <.0001).

Table 3 shows that the scores for autonomy in decision-making and respectful maternity care did not differ significantly between rural and metropolitan participants. When stratified by racialized identity, rural participants from racialized groups reported that they experienced significantly less respectful maternity care (score on MORi) than the White, non-Hispanic rural and all metropolitan participants (rural racialized 65.0, rural White, non-Hispanic 67.4, metropolitan racialized 65.2, and metropolitan White, non-Hispanic 68.3; p=.04).

Table 3.

Means and Standard Deviations of Scores on Measures of Respectful Maternity Care (MORi) and Maternal Autonomy in Decision Making (MADM), by Residency and Racialized Identity

Scalea Rural participants n = 299 Metropolitan participants n =1412 p value
M SD M SD
MORi 67.2 15.2 67.9 14.5 .45
MADM 30.8 10.7 30.8 10.6 .92
Racialized Rural n=31 White, non-Hispanic Rural n=268 Racialized Metropolitan n=176 White, non-Hispanic Metropolitan n=1236 p value
M SD M SD M SD M SD
MORi 65.0 16.7 67.4 15.0 65.2 16.4 68.3 14.2 .04*
MADM 29.2 12.6 31.0 10.4 29.2 10.9 31.1 10.5 .13
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a

Highest possible score: MORi = 84; MADM scale = 42;

*

p < 0.05

Qualitative Results

Of the participants (n=1151) who provided qualitative data in the open-ended question field, 204 (17.7%) identified their areas of residence as rural. Based on our analysis of the qualitative data, we identified four themes and provide additional sample quotes in Supplementary Table S2. We used race and state of residence as individual participant identifiers for each quotation. In the first theme, VBAC Not Available in Rural Communities, rural participants described the limited availability of VBAC in their communities and the choices they made when VBAC was not available. Rural participants emphasized their inability to access VBAC in their local communities, which was often the result of hospital policies that did not support routine care for VBACs (often referred to as “VBAC bans”) or the inability to find providers willing to provide VBAC: “My nearest VBAC hospital was about 2.5 hours away. My local hospital (5 minutes away) has a VBAC ban” (Multiracial, California). Rural participants described their response to lack of access to VBACs in their local communities in a variety of ways. As described in the second theme, Travelling Long Distances to Access Care for a VBAC, some participants travelled several hours to locate and access providers and/or hospitals that would offer a VBAC:

I did have to drive nearly 2 hours each way for access to a VBAC-supportive doctor and hospital…but I would do it all again in a heartbeat to have the choices that I had and support for them. Those simply don’t exist in my rural community (White, Missouri).

Another participant described a precipitous birth and her arrival at an out-of-state hospital just in time to give birth via VBAC:

My rural hospital performed VBACs at one time but has since changed their policy…It is their policy, however, to deliver VBACs if the mother has had one prior to the current pregnancy. That’s to say that you can have your second VBAC there, but not your first. We traveled out of state for my VBAC. The second child was nearly born in the parking lot (White, North Carolina).

Other participants opted for VBACs in out-of-hospital settings: “I drove 3 hours out of state to see my homebirth midwife because the OBs in rural eastern Kentucky wanted to schedule a repeat cesarean on my first prenatal appointment” (White, Kentucky).

Sometimes, because of the lack of availability of VBAC locally, rural participants had unexpected outcomes such as unplanned, unattended, homebirth after cesarean:

My second birth was very long: 80 hours with a 3-hour pushing stage. We drove 3 hours from home in order to have a VBAC. My third was an “oops” homebirth with my mother-in-law and sister present. My third labor was only around 90 minutes long and the ambulance got lost finding our rural home (White, Texas).

The third theme, Less Than Optimal Solutions, refers to the solutions chosen by other participants who felt that their circumstances and resources rendered them unable to access VBAC, and they settled for what they felt to be less desirable options:

We had to move and ended up in a pretty rural community where the hospitals don’t even consider VBACs an option. I didn’t want to have to drive over an hour to get to a hospital that was okay with the idea…so I settled on trying for a gentle [sometimes referred to as family centered] c-section (White, Washington).

In the fourth theme, Experiences of Rural Participants from Racialized Groups, racialized rural participants described disrespectful care they experienced. For example, an American Indian participant who lived in rural Oklahoma described the following:

With my last birth I had moved, and it took some work to find a doctor and hospital to do a VBAC. Only one hospital in Tulsa allows it. My local hospital in [town] denied my admission when I went to do pre-check in 5 weeks before my due date. Anesthesia scolded me on how stupid my decision was to have a VBAC and said they would not take my life into their hands, even though the admitting doctor who had seen me for 8 months had approved our joint plan of action: a repeat VBAC. So I had to travel an hour away 5 weeks before delivery to find a doctor that would care for us and a hospital that would deliver us (American Indian, Oklahoma).

Discussion

Participants with histories of cesarean who lived in rural communities described their subsequent birth experiences. Preference for VBAC was nearly universal among participants who lived in rural and metropolitan communities, and most participants said they were able to plan or attempt VBAC. Factors related to clinical care and support differed significantly for rural participants: fewer rural participants had the support of doulas for their subsequent births, and fewer had obstetricians than metropolitan participants. However, compared to national data (Declercq et al., 2014) doula support was higher and obstetrician (vs. midwife or family physician) care was lower for rural participants Many rural participants who desired VBAC had to travel for more than an hour to give birth and often bypassed local hospitals that did not provide routine care for VBAC.

Compared to metropolitan participants, rural participants were more likely to identify as White, non-Hispanic and were less educated, factors previously associated with a decreased likelihood of VBAC (Basile Ibrahim, Kennedy, & Holland, 2020). Yet when they “fought for their VBAC” (Basile Ibrahim, Knobf, et al., 2020) and gained access to providers and birth settings supportive of an attempt at VBAC, their rates of successful VBAC were similar to their metropolitan counterparts. This finding highlights the tenacity and commitment of rural participants who face disproportionate barriers, including decreased local availability of providers and hospitals willing to support VBAC, longer travel times to give birth, and less availability of dedicated doulas, to accessing evidence-based maternity care options.

With intersecting marginalized identities, participants who lived in rural communities and identified as members of racialized groups experienced significantly less respect during maternity care than White, non-Hispanic rural participants and all metropolitan participants. This finding is consistent with previous studies in which researchers found that non-Hispanic Black (Gadson et al., 2017) and African American (Salm Ward et al., 2013) women experienced maternity care that was more discriminatory, and Black, Indigenous, and women of color experienced care that was less respectful and autonomous (Basile Ibrahim et al., 2021; Vedam et al., 2019) compared to their White, non-Hispanic counterparts. Women who had hospital-based VBACs (Vedam et al., 2019), identified as women of color (Vedam et al., 2019), and who declined care (Attanasio & Hardeman, 2019) or had a difference in opinion about the best choice of care than their providers (Basile Ibrahim, Knobf, et al., 2020; Vedam et al., 2019) were more likely to report experiences of mistreatment or disrespect in interactions with their maternity care providers. Rural residents from racialized groups may face greater barriers to accessing care as a result of their rurality (greater travel distance to care, maternity workforce shortages, less access to specialty services; Kozhimannil, Henning-Smith, et al., 2016) and structural racism, which disproportionately harms Black and Indigenous people who give birth (Crear-Perry, Green, & Cruz, 2021). The intersection of racial injustice and geographic limitations on access to health care presents a pernicious challenge. The inequity revealed in our analysis likely contributes to the disproportionate burden of maternal and infant morbidity and mortality and premature death among rural residents and rural communities with a higher proportion of Black or Indigenous residents (Crear-Perry et al., 2021; Henning-Smith et al., 2019; Kozhimannil, Interrante, Tofte, et al., 2020).

Limitations

Limitations include self-reported data from a convenience sample. While our sample had a similar proportion of rural residents and rural Medicaid recipients as national data sources, and we included participants from each of the 50 states in the United States, the racial and ethnic distribution was not fully representative of childbearing women who live in rural areas across the United States. Potentially because of self-selection bias and recruitment via social media birth advocacy groups, our sample had a substantially higher VBAC rate than the national United States VBAC rate. Further, our sample size limited us from conducting in-depth analysis of subgroups of interest, such rural participants from racialized groups, or to stratify these participants further by racial or ethnic group.

Because the focus of this study was centered on the experiences of the participants rather than clinical outcomes, we did not ask participants to provide details about their clinical histories or considerations. Researchers found clinical considerations to be less important for patients when considering VBAC than social factors (Meddings et al., 2007), and clinical contraindications to VBAC are relatively rare (American College of Obstetricians and Gynecologists, 2019). Because the participants had a retrospective 5-year window from their subsequent pregnancies and births, recall bias may be present but is likely relatively minor. Researchers found that women were able to accurately recall detailed aspects of their births long after the event (Bat-Erdene et al., 2013; Marx, 2018).

Policy Implications

Rural participants showed a commitment to their health during pregnancy by accessing evidence-based care despite barriers. A range of clinical and policy strategies may be needed to improve women’s health during pregnancy via access to VBAC and increased VBAC rates for rural women. Rural participants were significantly more likely to be insured through Medicaid than metropolitan participants, which is consistent with previous research (Kozhimannil & Henning-Smith, 2018). Nationally, Medicaid insurance is associated with higher VBAC rates (Attanasio & Paterno, 2019; Basile Ibrahim, Kennedy, & Holland, 2020; Kozhimannil et al., 2013), which may be because more Medicaid participants give birth in urban academic medical centers where VBAC is more frequently available (Barger et al., 2013;).

Our findings are similar to national level data that show that a greater proportion of rural people rely on Medicaid for their health insurance (Kozhimannil & Henning-Smith, 2018). In our sample, 27.4% of rural participants were uninsured at some point since the birth of their first child, which is similar to prior findings (Dipietro Mager et al., 2020). This high proportion may be due to the fact that in many states, women become ineligible for pregnancy-related Medicaid 60 days after they give birth, and our participants were unable to secure other health insurance (Daw et al., 2017). Recent policy proposals to extend pregnancy-related Medicaid eligibility may benefit rural women who become uninsured in the postpartum period, and extended coverage could improve intra-pregnancy health, family planning, and potentially also financial security for rural residents. With more stable health insurance coverage among patients, rural health care facilities may be less likely to close and more likely to have greater capacity to expand service offerings, such as VBAC.

Receiving dedicated birth support from doulas (dedicated, non-clinical, birth support personnel) has been associated with positive birth outcomes, including lower rates of cesarean birth and higher rates of vaginal birth (ACOG Committee on Obstetric Practice, 2019; Gruber et al., 2013). Furthermore, women from racialized groups and with lower income may experience doula care as a buffer to the structural inequities that render them more vulnerable to poor outcomes (Kozhimannil & Hardeman, 2016). Doula services are not routinely reimbursed by health insurance providers (Kozhimannil & Hardeman, 2016), so many women pay out–of-pocket for these services, which can cost from $1200 to $2000 USD and are more readily available in urban areas (March of Dimes, 2022). Only a small number of states currently offer coverage for doula services through their Medicaid programs (National Health Law Program, n.d.; Platt & Kaye, 2020). Increasing access to doula care by covering these services through Medicaid may improve the experience of care, reduce unnecessary medical interventions and their associated risks and costs, and improve birth outcomes in communities where many residents participate in Medicaid during pregnancy and birth, including rural areas (March of Dimes, 2022).

Our analysis showed that one in five rural participants travelled more than 60 minutes to give birth, which is similar to the findings of other researchers (Kozhimannil, Casey, et al., 2016). Traveling for more than 60 minutes to give birth is associated with poorer perinatal outcomes (Grzybowski et al., 2011; Wallace et al., 2021). Nationally, 6.9 million women of childbearing age live in counties with low or no access to maternity care (March of Dimes, 2022). A majority (81%) of these 1,119 counties are classified as non-urban (March of Dimes, 2022). Maternity care deserts (counties without a hospital or birth center offering obstetric care and without any obstetric providers) in rural counties have a higher percentage of population in poverty, more women without health insurance, and lower median household income than counties with full access to maternity care and urban maternity care deserts (March of Dimes, 2022). Maternity care deserts may be created when rural hospitals close or cease their inpatient maternity care services. Rural hospitals that close their maternity care services tend to be smaller (Hung et al., 2016), located in more remote rural communities (Kozhimannil, Interrante, Tuttle, et al., 2020), in rural communities with higher proportions of Black residents, and in communities with more limited maternity care workforces (Hung et al., 2016, 2017). Closures of rural maternity units are associated with increases in births in hospitals without maternity units, out-of-hospital births, and preterm births (Kozhimannil et al., 2018), which places affected rural residents at further increased risk for negative outcomes.

Policies and programming aimed at increasing recruitment and retention of a variety of maternity-trained providers and nurses may increase the availability of VBAC in rural settings. Access to midwifery care is limited in many rural areas (Koschwanez et al., 2021; Minnesota Department of Health, 2013) and having a midwife for prenatal and birth care has been shown to increase the likelihood of VBAC (Basile Ibrahim, Kennedy, & Holland, 2020; Vedam et al., 2018). For rural residents, increasing the integration of midwifery into health systems and improving policies related to licensure, practice, and supervision (Vedam et al., 2018) may improve local availability of prenatal care (Leighton et al., 2019), which has been associated with improved maternal and infant outcomes (Powell et al., 2018). Efforts to expand access to professional and community health resources and support (e.g., doulas, lactation consultants, peer support networks) in rural communities could help increase local access and improve quality of care (Kennedy et al., 2020; March of Dimes, 2022; Vedam et al., 2018).

One method to achieve further integration is to improve Medicaid reimbursement for maternity care for a variety of credentialed providers and community support services (Higgins, 2015). Additionally, clinical and policy supports to recruit and retain nurses with experience and expertise in maternity care will ensure that hospitals can have adequate staffing to continue to offer labor and birth care, even at small-volume rural facilities (Henning-Smith et al., 2017). Further, system-level efforts to increase the number of rural providers that more closely reflect the races and ethnicities of the people served may improve outcomes for patients (Blanchard et al., 2007; Greenwood et al., 2020).

Conclusion

This analysis suggests that rural residents want the same options for birth after cesarean and quality of maternity care as metropolitan residents but often must overcome multiple social and geographic barriers to access this evidence-based care. Our data highlight that many rural residents persist in attempts to access VBAC and potentially travel long distances when this service is not available locally. To improve health equity across race and place, it is essential to amplify the voices of rural women, especially those from racialized groups and to improve access for all women to the same high-quality, evidence-based options that are available in metropolitan areas.

Supplementary Material

1

  1. Rural residents, especially those from racialized groups, have inequitably high rates of maternal and infant mortality and low rates of vaginal birth after cesarean.

  2. Rural participants who were members of racialized groups had significantly lower mean scores on a measure of respect in maternity care than their rural, White, non-Hispanic and metropolitan counterparts.

  3. Policies that increase the availability of midwifery care in rural hospitals may improve rural residents’ access to vaginal birth after cesarean and high quality, respectful maternity care.

Funding

Supported by the Margaret Comerford Freda Saving Babies, Together Award (Association of Women’s Health, Obstetric, and Neonatal Nurses and March of Dimes) and the Rockefeller University Heilbrunn Family Center for Research Nursing.

Footnotes

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Disclosure

The authors report no conflicts of interest or relevant financial relationships.

Contributor Information

Bridget Basile Ibrahim, Yale University School of Nursing, Orange, CT.

Katy Backes Kozhimannil, Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN.

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