Severe Maternal Morbidity in the Rural United States: State of the Science

Severe maternal morbidity (SMM) is a pervasive adverse health outcome in the United States, affecting 50,000 to 60,000 pregnant individuals annually. Rural communities experience a convergence of factors that place them at higher risk of SMM. This state of the science review synthesizes current evidence regarding SMM in the rural United States, using an intersectional lens to critically evaluate the complex dynamics influencing SMM in these communities. We reviewed 32 studies published in the last 10 years, from which 3 broad themes emerged. First, rural residency is an independent risk factor for SMM, with risk increasing alongside greater geographic remoteness, even after adjusting for sociodemographic factors and medical comorbidities. Second, racial and ethnic disparities in SMM are wider in rural communities compared with their urban counterparts, indicating that geographic isolation and structural racism interact to create unique pressures on minoritized populations. Third, the pattern of SMM attributable to specific health risks and conditions diverges between rural and urban communities. Rural residents experience a greater proportion of SMM due to hypertensive disorders, chronic condition-related decompensation, severe hemorrhage, and mental health conditions. These findings highlight a significant measurement gap, wherein current national surveillance may systematically undercount SMM indicators most prevalent in rural communities. Future perinatal health research must validate rural metrics, use intrarural classifications to explore the nuance of place-based outcomes, and prioritize intersectional investigations viewing rurality as a structural driver with complex and nonuniform effects. Theory-guided research of rural communities is critically needed to build a comprehensive understanding of rural SMM, address persistent inequities, and create effective perinatal health interventions.