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Mothers-to-be who live in rural areas are more likely than urban women to suffer severe complications during their pregnancies and deliveries, according to a new study that comes after a slew of closures of small-town birthing units across the country.
The new paper, published Monday in the Canadian Medical Association Journal, examined every birth in British Columbia between 2005 and 2010 to see if there was any difference in maternal outcomes between city-dwelling women and their counterparts in remote corners of the province.
Sarka Lisonkova, a professor in the department of obstetrics and gynaecology at the University of British Columbia, said that plenty of research has looked at outcomes for rural newborns, "but oftentimes the mother gets forgotten."
"So I wanted to specifically look at maternal morbidity," she said.
After poring over data about 256,220 B.C. women – 10 per cent of whom lived in rural areas – Dr. Lisonkova and her co-authors found a "significant two-fold increase" in the rates of serious complications such as eclampsia, obstetric embolism and uterine rupture in rural women over their urban and suburban sisters.
"I thought we wouldn't find big differences," Dr. Lisonkova said, "but I was surprised, actually, that there were some differences in some conditions that can be potentially life-threatening."
The study did not pinpoint why rural women are more prone to serious problems while giving birth, something Dr. Lisonkova acknowledged was "difficult to untangle."
She theorized that rural women have both a harder time accessing good prenatal care – including ultrasounds – and a harder time travelling swiftly to far-flung hospitals to deliver.
Rural areas also tend to have higher rates of teen pregnancy, smoking, obesity, substance abuse and chronic medical conditions, but the study controlled for those factors and still found rural mothers had a higher likelihood of suffering complications.
Still, Dr. Lisonkova stressed that the overall rate of severe problems during pregnancy and delivery was low.
"These conditions are rare," she said. "It's not like we are having an epidemic of life-threatening maternal conditions. But having said that, the risks are higher [for rural women.] It's important to know, because if these women are potentially facing geographic or other barriers they need to be more carefully monitored."
George Carson, the president of the Society of Obstetricians and Gynaecologists of Canada, agreed, saying the health-care system needs to be particularly thoughtful about how it mitigates peril for pregnant women in remote areas.
Rural women can perhaps lower their health risk by moving temporarily to the city before their due dates, he said. But uprooting women from their families and communities as they prepare to give birth can be risky in a different way.
"If women don't have their babies in the community, the only reason anybody goes to hospital is to die," said Dr. Carson, who is also the director of maternal-fetal medicine for the Regina Qu'Appelle Health Region in Saskatchewan. He was not involved in the B.C. research.
"It takes away the balance. It takes away a lot of the vitality of a community if you take the having of babies, the formation of new families, out of the community. So while there may be a small increased risk with having babies in rural places, not having babies in rural places has a huge impact too."
More than 40 birthing units, most in rural and small-town Canada, have closed in the last decade, The Globe and Mail found in a survey of provincial health ministries last year. Six of those were in B.C.
Some shut down because they struggled to retain specially trained doctors and nurses. Others delivered so few babies that officials feared patient safety could be comprised. Most faced budgetary challenges, too.
While the new B.C. study focused on mothers, it also looked at how their newborns fared.
The researchers found no difference in the mortality rate between rural and urban babies, but they concluded the rural infants were more likely to be born prematurely, to be large for their gestational age and to score poorly on a test of their well-being taken five minutes after birth.
However, they were less likely than urban babies to be admitted to the neonatal intensive care unit.
Both Dr. Lisonkova and Dr. Carson surmised that was because of how much easier it is to move a baby born in an urban hospital to a nearby NICU.
"If there is an intensive care nursery available, the threshold for admission to the intensive care nursery may be slightly lower when it's there than it is if you were in a place where the nearest intensive care nursery was two or three hours away," Dr. Carson said.
Kelly Grant