Reproductive Health Care in the Rural United States | JAMA | JAMA Network
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January 2, 2002

Reproductive Health Care in the Rural United States

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JAMA. 2002;287(1):112. doi:10.1001/jama.287.1.112-JMS0102-6-1

In addition to rural health care barriers such as poverty and distance, rural women face limited access to reproductive health services.1 The resulting lack of care can challenge rural women's reproductive autonomy. Their reproductive choices may also be limited by the added impact of rural values, norms, and belief systems regarding sexual health and the patient-physician relationship. Rural women tend to have less education, fewer job opportunities, lower salaries, more children, and greater family caretaking responsibility than their urban counterparts.1 They are more likely both to marry and to have children at younger ages. The combination of poverty, low population density, and lack of child care and other services in many rural areas reinforces traditional roles for women. They receive less preventive care than women in urban areas and have higher rates of chronic disease.1

Rural women are more likely to lack private insurance due to the structure of local economies and conditions of employment.2 Rural women, especially those of Hispanic ethnicity, are less likely than urban women to obtain adequate prenatal care.3 Rural women's isolation, lack of transportation, and confidentiality concerns, as well as the lack of culturally competent educational materials and staff to meet the needs of immigrant women, pose challenges to quality reproductive health care in rural settings. Rural locales are also challenged by lower than average reimbursement for physicians, chronic physician shortages in general, and a loss of obstetrician-gynecologists in particular.4

Hospital closures and mergers further constrain options in the sparse rural landscape. Although acquisitions of nondenominational hospitals by Catholic health care systems have led to a loss of reproductive health care services in both urban and rural areas, rural women may feel the loss of such services more acutely when a Catholic hospital becomes the sole health care facility in their region.5 Rural residents may increasingly find that hospitals serving their geographic area no longer provide essential services such as family planning,6 HIV/AIDS counseling and testing,6 emergency contraception for women who have been raped,7 infertility treatments,6 or tubal ligation.6 Even for routine preventive care, the cost and time involved in reaching a more distant site may create strong disincentives.

Despite the popular stereotype of adolescent pregnancy as an inner-city problem, the rates of adolescent pregnancy are similar in urban and rural areas.8 However, adolescent birth rates may be higher in rural vs urban counties due to lower rates of abortion.8 In 1996, only 5% of all rural counties in the US had abortion services and only 1% of abortions were reported in rural counties.9 Although an increasing number of physicians may be willing to offer medical abortions, those who do so must be qualified to provide surgical abortion, or have referral arrangements with a physician who performs abortion procedures. Rosenblatt et al10 found that nearly 50% of rural Idaho physicians would not refer their patients to another provider for abortion procedures. Given the small number of physicians who currently perform abortions in rural locales, medical abortion may not be an option in many rural areas.

Due to the lack of qualitative data regarding fertility decision making among rural women, it is not currently known whether their low abortion rates are due solely to limited physician access. A survey of Washington State's 31 rural family planning clinics found that abortion services were not provided, in part, due to federal funding prohibitions, local community opposition, lack of a trained provider, and steep increases in medical liability insurance.11 There is a need for further studies to examine rural abortion and contraceptive practices as they relate to sexual health education in rural schools, socioeconomic status, degree of religiosity, and prevailing social norms and preferences.

Regionalized perinatal care has provided life-saving technologies for treatment of high-risk women and infants since the 1960s. However, far fewer rural than urban women designated as high-risk delivered their infants in hospitals equipped with advanced levels of technology in 1988 (28% vs 51%).12 Some observers fear that economic pressures to limit referrals could endanger services to vulnerable pregnant women in rural areas.12 Evolving US health policy, rationalization of resources, and efforts to achieve universal health care must be attentive to reproductive health care needs, including the special needs of rural women, children, and families.

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