Maternal and Child Health Research Consortium - Rural populations in the United States experience significantly worse birth outcomes than urban peers. This difference is set against the highest maternal mortality rate of any high-income country globally and the persistent closing of rural obstetric units, especially in impoverished communities. Half of rural counties in the US no longer have a hospital with a birthing unit, leaving nearly 7 million people without timely access to childbirth services and at risk for poor birth outcomes due to geographic risk. Despite this large and growing problem, the list of solutions for rural women and their remaining obstetric units is small. Research describing innovative and effective solutions to improve rural maternity care access is therefore urgently needed. Elective induction of labor (eIOL39), or artificially starting labor with medications or clinal procedures, is a potential avenue for helping to narrow the gap between rural and urban birth outcomes by getting pregnant women to their facility of choice before labor begins. Recent evidence, including a large trial in 2018, shows that eIOL39 is as safe as waiting for labor and may reduce the rates of cesarean section and hypertensive disorders of pregnancy. The American College of Obstetricians and Gynecologists now says that eIOL39 should be offered as an option to eligible women and may be particularly useful for those living far away from their birth facility. They also recommend good counseling on the risks and benefits of eIOL39. The new evidence and recommendations have led to a significant rise in eIOL39 in the country from 12.6% of births before the 2018 trial to 17% post-trial. eIOL39 rates in rural populations are not well documented in the literature. Despite the rise in induction, patients, providers, and managers describe concerns about eIOL39. Patients talk about the “cascade of intervention” triggered by induction and worry about loss of control during childbirth. Many providers, especially midwives, also worry about overmedicalization of birth. Second, the research behind eIOL39 was conducted in high-volume facilities, potentially limiting its generalizability to rural hospital settings. Third, providers and managers cite the logistical complications of implementing eIOL39 in small rural facilities. Finally, the tools and decision-aids to help rural patients and providers come to a shared decision are not yet available. We are a group of rural maternity care providers and researchers across seven states (Nebraska, Colorado, West Virginia, Georgia, Maine, New Hampshire, and Vermont) who will work collaboratively to address these gaps through four key objectives: 1) develop a research network focused on rural maternity care; 2) conduct three studies related to eIOL39 to mitigate geographic risk; 3) disseminate and translate findings across academic and service delivery platforms; 4) mentor early career investigators interested in rural maternity care. For our first study we will use Medicaid insurance claims data to describe the rates and patterns of elective induction and related birth outcomes in rural versus urban populations nationally. In the second study we will analyze the challenges that rural facilities in our states face in offering eIOL39 and what strategies they are using to overcome these challenges. In the third study we will adapt a shared decision-making tool for rural settings and test the impact of its use in our states on patient understanding of the options and outcomes of their decisions, their involvement in decision-making, and the extent to which they receive treatment that aligns with their values and goals. Our work and methods are rooted in participatory implementation science and are intended to produce practical and actionable information for rural populations and their maternity care providers.
