Risk-Appropriate Childbirth Care Among Higher-Risk Pregnant Rural Residents.

Importance: With hospital-based obstetric care declining in rural areas, risk-appropriate care, which aligns patient clinical conditions with hospital capabilities using level of care, may be limited for pregnant rural residents, especially those with higher-risk conditions that necessitate specialty or subspecialty obstetric care. Objective: To assess the proportion of higher-risk pregnant rural residents who receive risk-appropriate care during childbirth and identify factors associated with not receiving risk-appropriate care. Design, Setting, and Participants: This cross-sectional study used linked vital statistics and hospital discharge data for pregnant rural residents with higher-risk clinical conditions who had hospital-based births in Michigan (2010-2020), Oregon (2010-2020), Pennsylvania (2010-2018), and South Carolina (2010-2020). Data analyses were performed between December 2023 and July 2025. Exposure: Birth hospital maternal level of care (I, basic; II, specialty; III, subspeciality; IV, regional perinatal). Main Outcomes and Measures: The main outcome was birth in a hospital with risk-appropriate care, defined as having the necessary level of care for the patient's clinical condition. Covariates included age, race and ethnicity, insurance, education, prenatal care utilization, medical and obstetric comorbidities, distance to the closest risk-appropriate hospital (quartile 1: 0.50-5.57 miles, quartile 2: 5.58-18.90 miles, quartile 3: 18.91-33.93 miles, quartile 4: 33.94-209.80 miles), year, and state. Results: A total of 199 225 higher-risk pregnant rural residents (mean [SD] maternal age, 27.9 [5.6] years) were included, of whom 11 651 (5.9%) identified as Hispanic, 3054 (1.5%) as non-Hispanic American Indian or Alaska Native, 1370 (0.7%) as non-Hispanic Asian or Pacific Islander, 18 296 (9.2%) as non-Hispanic Black, 5320 (2.7%) as non-Hispanic other race, and 159 253 (79.9%) as non-Hispanic White. Birth at a risk-appropriate hospital occurred for 38 441 of 70 647 individuals (54.4%) with conditions requiring level II care, 4611 of 9270 (49.7%) with conditions requiring level III care, and 1793 of 6527 (27.5%) with conditions requiring level IV care. Those with significantly higher rates of not receiving risk-appropriate care included American Indian or Alaska Native (adjusted incidence rate ratio [aIRR], 1.13; 95% CI, 1.10-1.17), or Hispanic (aIRR, 1.06; 95% CI, 1.03-1.08) individuals (compared with White individuals), those without private insurance (public: aIRR, 1.03; 95% CI, 1.01-1.04; uninsured: aIRR, 1.07; 95% CI, 1.01-1.14), those who were younger and had less education (age <20 years: aIRR, 1.05; 95% CI, 1.03-1.08, compared with 30-34 years; some high school: aIRR, 1.04; 95% CI, 1.03-1.06, compared with high school degree), and those who lived further from a risk-appropriate hospital (furthest quartile: aIRR, 23.86; 95% CI, 20.48-27.79, compared with closest quartile). Conclusions and Relevance: In this study, lack of risk-appropriate care was common for pregnant rural residents with clinical complexity. Associated factors, including race, ethnicity, insurance, age, education, and distance, highlight the barriers and need for increasing access to subspecialty care for pregnant rural residents.