Maternal Geographic Residence and Obstetric Care Access in Relation to Delivery Method Among Individuals With Low-Risk Term Births in the United States

OBJECTIVE: To assess associations among maternal geographic residence, access to obstetric care, and nonspontaneous delivery, including labor induction and prelabor cesarean delivery, in individuals with low-risk term pregnancies. METHODS: We analyzed cross-sectional 2022 National Center for Health Statistics natality data, restricted to individuals with healthy, low-risk, term (37-40 weeks of gestation) singleton births. Maternal residence was classified along the rural-urban continuum and county-level maternity care access designations. Deliveries were categorized as spontaneous (reference) or nonspontaneous (ie, clinician initiated) and further classified as induction or prelabor cesarean. Cox proportional hazards models (with data augmentation as appropriate) were used to estimate hazard ratios (HRs) adjusted for maternal age, race and ethnicity, prepregnancy body mass index (BMI), and cigarette smoking status. RESULTS: Among 1,157,422 low-risk term births, residents of rural and limited-access counties had a higher incidence of nonspontaneous delivery, particularly at 39-40 weeks of gestation, compared with residents of urban and full-access counties (adjusted HR 1.22 in suburban to 1.42 in the most rural counties, P trend<.01; adjusted HR 1.25 in moderate- to 1.43 in no-access counties, P trend<.01). This finding was driven by induction (observed in 34.4% of full-term deliveries; adjusted HR 1.31 in suburban to 1.56 in the most rural counties; P trend<.01; adjusted HR 1.33 in moderate- to 1.52 in no-access counties, P trend<.01). The opposite pattern was observed for prelabor cesarean delivery (4.8% of deliveries; adjusted HR 0.69 in suburban to 0.61 in the most rural counties, P trend<.01; adjusted HR 0.70 in moderate- to 0.79 in no-access counties, P trend<.01). Associations for the rural-urban continuum were driven largely by maternity care access: adjusted HR 1.05 for nonspontaneous delivery in rural/full-access counties and 1.39 in urban-suburban/no-access counties compared with urban-suburban/full-access counties. All associations were attenuated at 37-38 weeks of gestation compared with 39-40 weeks. CONCLUSION: Maternal residence and access to obstetric care were associated with the timing and method of delivery among individuals with low-risk pregnancies, possibly reflecting differences in health care system capacity and local practice norms. Declining local access to maternity care may contribute to increased reliance on labor induction in rural and limited-access settings.