Original Article
A scoping review of adverse birth outcomes in women from rural and urban areas
2025 年 13 巻 3 号 p. 54-67
詳細
2025 年 13 巻 3 号 p. 54-67
Aims: The place of residence influences the occurrence of adverse birth outcomes, and understanding disparities in adverse birth outcomes between rural and urban areas is crucial for designing targeted interventions and improving maternal and neonatal health outcomes.
Methods: A scoping review using five databases, including the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Medline, PubMed, and Web of Science, was conducted to evaluate the association between the place of residence (rural and urban areas) and adverse birth outcomes.
Results: A total of 15 studies met the inclusion criteria and were included in this review. Nine adverse birth outcomes (preterm birth, low birth weight, small for gestational age, perinatal death, stillbirth, neonatal death, large for gestational age, cesarean section, and miscarriage) were reported to have higher rates in rural versus urban communities.
Conclusions: Inadequate access to antenatal care services and limited healthcare facilities were identified as potential factors contributing to the higher likelihood of adverse birth outcomes in rural areas. Targeted interventions tailored to the specific challenges faced by rural communities should be implemented to ensure equitable access to healthcare services and optimal maternal and neonatal health.
Not all childbirth experiences are positive, and negative or adverse childbirth outcomes affect both mothers and infants.1) Among such adverse birth outcomes are preterm birth (PTB), small for gestational age (SGA), low birth weight (LBW), large for gestational age (LGA), perinatal death, cesarean section (CS), miscarriage, stillbirth, and neonatal death.2,3,4,5,6,7) Adverse birth outcomes are associated with an increased risk of newborn mortality and morbidity, as well as growth and development issues, especially in low- and middle-income countries (LMICs).8,9)
Globally, adverse birth outcomes affect millions of newborns10) and have been reported to be more common in developing countries than in developed countries.11) In LMICs, 23.3 million infants were born SGA, of which 1.5 million were PTB (<37 weeks of gestation at birth) and 10.7 million were LBW births (<2,500 grams birth weight), in 2012.12) For perinatal death, an estimated 5.1 million stillbirths and neonatal deaths were reported worldwide in 2018, and 98% of these deaths occurred in LMICs, with more than 75% occurring in sub-Saharan Africa and South Asia.13) In high-income countries, the prevalence of gestational age childbirths is 5%–20%.14) Globally, 18.6% of all deliveries reported from 150 countries were by CS (range: 1.4% to 56.4%).15) Miscarriages occur in an estimated 23 million pregnancies annually worldwide, translating to 44 miscarriages every minute.16)
Adverse outcomes are a multifactorial feto-maternal health condition. They are influenced by a number of biological, social, and environmental factors.17) Several studies have found that factors such as maternal education,18) marital status,19) intention to be pregnant,20) and adolescent pregnancy21) are linked to poor birth outcomes. Women with high levels of education have an ability to read newspapers and other sources of information, such as banners and billboards,22) which are intended to help women better understand and expand health knowledge.23) This may explain the increased access to maternal healthcare among women with higher levels of education than those with lower levels. In relation to marital status, married women are less likely to have adverse birth outcomes than unmarried women,19) and newborns without a father’s name on their birth certificates have a higher infant morbidity and mortality rate.24) The higher risk of adverse birth outcomes among unmarried women may be related to the poor social support system they receive compared with married women. For instance, a study found that unmarried women have a perceived lack of emotional support.25)
Compared with intended pregnancies, unintended pregnancies are at increased risk of adverse maternal and neonatal outcomes.26) One study27) reported that, because of unawareness of pregnancy, women with unintended pregnancies may be exposed to teratogens, such as alcohol, medications, cigarette smoking, and X-rays, which are risk factors for adverse birth outcomes.28,29,30) With regard to adolescent pregnancy, risk factors include substance abuse, lack of availability of contraceptives, early sexual activity, low levels of access to health services, limited maternal education, poverty, lack of parental support, and lack of financial autonomy,31,32) which put adolescent women at increased risk of adverse birth outcomes.33,34,35)
Adverse birth outcomes are significantly more likely in rural than urban communities36,37,38); this is linked to historically greater difficulties in healthcare access and utilization in rural areas compared with metropolitan urban areas.39) One study reported that mothers residing in rural regions had greater risks of anemia, preterm delivery, post-term pregnancies, LBW, neonatal resuscitation, and newborn intensive care unit admission, although the rate of CS was lower.17) This can be explained by the situation in both rural and urban areas. In remote and rural communities, the availability of and access to healthcare services are limited or costly, and there is a lack of healthcare experts and a high turnover rate.40,41) Women from remote or very remote communities are more likely to travel to another city or town to give birth at a hospital with an appropriate level of care than those from major cities (65.9% vs 13.8%),42) as well as have a higher rate of out-of-hospital births (4.2% vs 0.7%),43) less access to private hospitals during childbirth (28.7% vs 46.1%), less access to specialist obstetric care during childbirth (59.2% vs 69.7%), and later antenatal care initiation (antenatal appointment by 18 weeks of pregnancy [37.4% vs 71%]).42)
Compared with major cities, maternal services in rural and remote areas are less likely to be planned and maintained according to the number of births and service needs, which could be attributed to differences in planning across states and territories.44) For example, there was a significant difference across state jurisdictions, with more inequitable planning in Queensland and South Australia compared to New South Wales (NSW). Geographical areas with a high proportion of First Nation peoples were also more likely to have inequitable health service planning and maintenance.45) Poor health service planning and maintenance are associated with lower quality and continuity of services and worse pregnancy outcomes in rural and remote areas.46,47,48) However, while the previous reports suggested rural-urban disparities in adverse birth outcomes, comparisons between adverse birth outcomes in rural and urban communities have not been fully explored. Therefore, this review aimed to summarize and synthesize studies that have compared adverse birth outcomes between rural and urban areas. Five databases, including the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Medline, PubMed, and Web of Science, were searched to identify eligible studies, which were summarized and synthesized using systematic review methods. Commonly reported adverse birth outcomes in the literature2,3,4,5,6,7) were selected for inclusion in this review: PTB, SGA, LBW, LGA, perinatal death, CS, miscarriage, stillbirth, and neonatal death.2,3,4,5,6,7) By synthesizing existing research on urban-rural disparities in adverse birth outcomes, this review aims to contribute to the design of targeted healthcare interventions and policy improvement related to maternal and infant health.
This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.49)
Search strategy and study selectionTo identify relevant studies reporting on adverse birth outcomes, comprehensive searches were conducted in five databases: CINAHL, Embase, Medline, PubMed, and Web of Science. The searched sources were published between 2005 to 2023. The following search terms were used: “rural” or “rural areas” or “rural communities” or “urban” or “urban areas” or “urban communities” in combination with “adverse birth outcome” or “adverse pregnancy outcome.” All sources retrieved from the search engines were managed using EndNote 20 for efficient organization. The articles were initially screened by title and abstract review for their relevance, specifically, studies on adverse birth outcomes in relation to the type of residence (rural and/or urban). Subsequently, full-text articles were obtained for further assessment of inclusion. The inclusion criteria required the studies to be empirical, published in peer-reviewed journals, and examine the association between the type of residence (rural or urban) and adverse birth outcomes. The studies also needed to have full-text available and be published in English. Following the removal of duplicate studies, two independent reviewers (EBFD and IDS) conducted a thorough evaluation of the remaining articles for eligibility. In cases where disagreements or uncertainties arose, discussions were held to reach a consensus, and if necessary, a third reviewer was consulted for additional input. Moreover, reference lists of the selected articles were scrutinized to identify potentially relevant studies that were not captured in the initial search.
Data extractionData were extracted and recorded, including author details (name, date of publication), study details (country, study design), study population characteristics, and adverse pregnancy outcomes in rural and urban areas.
Quality assessmentThe JBI checklist consists of specific criteria tailored to different study designs. For cohort studies, an 11-criterion JBI checklist was used,50) and for cross-sectional studies, an eight-criterion checklist was used.51) Case control studies were evaluated using a 10-criterion JBI checklist.52) Initially, two authors (EBFD and IDS) independently evaluated the collected studies for methodological quality using the relevant JBI checklist. Any disagreements between the reviewers were resolved through discussions and consensus. Each criterion in the JBI checklist was assigned a score of 2 points (Yes), 0 points (No), or 1 point (Unclear). These scores were then converted to percentages. In order to ensure the methodological quality of the studies included in the review, a minimum score of 70% was required for each study, following the criteria established by Fernandez et al..53) Adhering to these criteria, no studies were excluded based on their methodological quality. In cases where disagreements between the two reviewers could not be resolved, a third reviewer (FWL) was consulted to reach a resolution.
Definition of adverse pregnancy outcomeAdverse birth outcome is synonymous to pregnancy outcome,54) which explains why both search terms were included in the present review. The World Health Organization (WHO) has provided specific definitions for various adverse pregnancy outcomes. LBW is defined as a weight at birth of less than 2,500 grams (5.5 pounds).55) PTB refers to the delivery of a baby before 37 weeks of gestation.56) SGA is a term used to describe newborns who have a size smaller than expected for their gestational age, typically defined as a weight below the 10th percentile for gestational age;57) conversely, LGA is defined as a birth weight exceeding the 90th percentile for gestational age.58) Perinatal death refers to the death of a baby that occurs from 28 weeks of gestation onwards and within the first seven days after birth.59) Stillbirth refers to the death of a newborn within the first seven days after birth, while neonatal death refers to the death of a newborn within the first four weeks after birth.59) CS is a surgical procedure in which a fetus is delivered through an incision made in the abdominal wall and uterus.60) Miscarriage is a spontaneous fetal death before 22 weeks of gestation.61)
The comprehensive search strategy yielded a total of 1,838 studies. In addition, three articles were identified by reviewing the reference lists of relevant articles and reviews, bringing the total number of articles to 1,841. Through the use of EndNote software, 629 duplicate studies were removed when the names of authors and titles were the same. After removal of duplicate studies, the titles and abstracts of 1,221 articles were screened for eligibility. Studies were excluded if they did not align with the topic of the review, if they did not include the type of residence as an independent variable, or if they were review articles. Following the screening process, a total of 15 studies published between January 2005 and June 2023 were found to meet the inclusion criteria and were included in the review17,61,62,63,64,65,66,67,68,69,70,71,72,73,74) (Figure 1).
The review encompassed 15 articles published between 2005 and 2023, conducted across three continents: Africa, North America, and Asia. Among these articles, eight were cross-sectional studies,17,61,63,64,65,66,68,71) six were cohort studies,62,67,69,70,72,73) and one was a case-control study.74) All studies examined short-term adverse birth outcomes in both rural and urban areas. Ten of the selected adverse outcomes, which are commonly reported in the literature, are summarized in this review.10,75,76) None of the studies investigated long-term adverse birth outcomes among women in rural and urban areas.
The studies included in this review treated the type of residence (rural/urban) as an independent variable associated with the occurrence of adverse birth outcomes. Study populations varied from Americans to Canadians, Nepalis, Ethiopians, Chinese, Tanzanians, Ghanaians, and Iranians. Most of the studies were retrospective studies and did not specify the timing of assessment of adverse birth outcomes. Ten studies included multiple adverse birth outcomes, while five focused on a single type of adverse birth outcome. The adverse birth outcomes covered in this review included LBW, PTB, SGA, perinatal death, stillbirth, neonatal death, LGA, CS, and miscarriage. Six studies provided the age range of women included in their analyses, while the remaining nine did not specify the age range of their female participants; one study explicitly stated that participants were women aged 35 years or older, four studies included women aged 15–49 years, and one study focused on adolescent women aged 15–19 years. Due to significant heterogeneity among the studies and lower quality assessment scores for some of them, a meta-analysis was not performed, as it could potentially yield inaccurate estimates of the overall effect size.77)
Quality assessment of included studiesQuality assessment of the 15 included studies demonstrated scores ranging from 75% to 100%, with an average score of 92.5%. One study scored 75%, three scored 82%, two scored 88%, one scored 91%, and eight scored 100% (Tables 1, 2, and 3). Studies that scored below 100% generally exhibited unclear strategies for addressing and controlling confounding factors. It is important to note that the majority of studies included in this review were retrospective in design, which limited their ability to effectively control for confounders. Despite the varying risk of bias ratings, all 15 studies were included for analysis in the narrative review (Table 4).
| Checklist | Lisonkova et al. (2011) | Khanal et al. (2016) | Shan et al. (2018) | Amjad et al. (2019) | Tarimo et al. (2020) | Mboya et al. (2020) |
|---|---|---|---|---|---|---|
| 1. Were the two groups similar and recruited from the same population? | Y | Y | Y | Y | Y | Y |
| 2. Were the exposures measured similarly to assign people to both exposed and unexposed groups? | Y | Y | Y | Y | Y | Y |
| 3. Was the exposure measured in a valid and reliable way? | Y | Y | Y | Y | Y | Y |
| 4. Were confounding factors identified? | N | N | Y | Y | Y | U |
| 5. Were strategies to deal with confounding factors stated? | N | N | Y | Y | Y | U |
| 6. Were the groups/participants free of the outcome at the start of the study (or at the moment of exposure)? | Y | Y | Y | Y | Y | Y |
| 7. Were the outcomes measured in a valid and reliable way? | Y | Y | Y | Y | Y | Y |
| 8. Was the follow up time reported and sufficient to be long enough for outcomes to occur? | Y | Y | Y | Y | Y | Y |
| 9. Was follow up complete, and if not, were the reasons for loss to follow up described and explored? | Y | Y | Y | Y | Y | N |
| 10. Were strategies to address incomplete follow up utilized? | Y | Y | Y | N | Y | Y |
| 11. Was appropriate statistical analysis used? | Y | Y | Y | Y | Y | Y |
| Total score | 18/22 (82%) | 18/22 (82%) | 12/12 (100%) | 20]22 (91%) | 12/12 (100%) | 18/22 (82%) |
Y, yes; N, no; U, unclear.
| Checklist criteria | Hillemeier et al. (2007) | Bailey et al. (2009) | Auger et al. (2009) | Mengesha et al. (2017) | Li et al. (2018) | Bhusal et al. (2019) | Ahinkorah et al. (2021) | Mehrnoush et al. (2023) |
|---|---|---|---|---|---|---|---|---|
| 1. Were the criteria for inclusion in the sample clearly defined? | Y | Y | Y | Y | Y | Y | Y | Y |
| 2. Were the study subjects and the setting described in detail? | Y | Y | Y | Y | Y | Y | Y | Y |
| 3. Was the exposure measured in a valid and reliable way? | Y | Y | Y | Y | Y | Y | Y | Y |
| 4. Were objective, standard criteria used for measurement of the condition? | Y | Y | Y | Y | Y | Y | Y | Y |
| 5. Were the confounding factors identified? | U | Y | Y | Y | Y | N | Y | Y |
| 6. Were strategies to deal with confounding factors stated? | U | N | Y | Y | Y | N | Y | Y |
| 7. Were the outcomes measured in a valid and reliable way? | Y | Y | Y | Y | Y | Y | Y | Y |
| 8. Was appropriate statistical analysis used? | Y | Y | Y | Y | Y | Y | Y | Y |
| Total score | 14/16 (88%) | 14/16 (88%) | 16/16 (100%) | 16/16 (100%) | 16/16 (100%) | 12/16 (75%) | 16/16 (100%) | 16/16 (100%) |
Y, yes; N, no; U, unclear.
| Checklist | Woday et al. (2019) |
|---|---|
| 1. Were the groups comparable other than the presence of disease in cases or the absence of disease in controls? | Y |
| 2. Were cases and controls matched appropriately? | Y |
| 3. Were the same criteria used for identification of cases and controls? | Y |
| 4. Was exposure measured in a standard, valid, and reliable way? | Y |
| 5. Was exposure measured in the same way for cases and controls? | Y |
| 6. Were the confounding factors identified? | Y |
| 7. Were strategies to deal with confounding factors stated? | Y |
| 8. Were outcomes assessed in a standard, valid, and reliable way for cases and controls? | Y |
| 9. Was the exposure period of interest long enough to be meaningful? | Y |
| 10. Was appropriate statistical analysis used? | Y |
| Result | 20/20 (100%) |
Y, yes; N, no; U, unclear.
| Author (Year) | Country | Study design | Population | Sample size |
|---|---|---|---|---|
| Hillemeier et al. (2007) | Central Pennsylvania, USA | Cross-sectional study | Women with singleton first births | 11,546 |
| Bailey et al. (2009) | Southern Appalachia county, USA | Cross-sectional study | Women with live singletons surviving nursery assignment | 4,144 |
| Auger et al. (2009) | Québec, Canada | Cross-sectional study | Women with singleton births | 356,147 |
| Lisonkova et al. (2011) | British Columbia, Canada | Cohort study | Women ≥35 years old who delivered a singleton stillborn or live infant | 29,698 |
| Khanal et al. (2016) | Rupandehi district, Western Nepal | Cohort study | Women aged 15–45 years with singleton births | 735 |
| Mengesha et al. (2017) | Tigray, Northern Ethiopia | Cross-sectional study | Women with live births in selected public hospitals | 1,162 |
| Li et al. (2018) | China | Cross-sectional study | Women with pre-eclampsia | 1,396 |
| Shan et al. (2018) | China | Cohort study | Women with singleton births | 2,800 |
| Amjad et al. (2019) | Alberta, Canada | Cohort study | Adolescent women aged 15–19 years with singleton live births | 9,606 |
| Bhusal et al. (2019) | Nepal | Cross-sectional study | Women aged 15–49 years | 8,918 |
| Woday et al. (2019) | Amhara region, Ethiopia | Case-control study | Women who gave birth at public hospitals | 134 cases, 268 controls |
| Tarimo et al. (2020) | North Tanzania | Cohort study | Women who delivered with induction of labor intervention | 1,088 |
| Mboya et al. (2020) | Northern Tanzania | Cohort study | Women aged 15–49 with singleton live births | 50,847 |
| Ahinkorah et al. (2021) | Ghana | Cross-sectional study | Women aged 15–49 years | 25,062 |
| Mehrnoush et al. (2023) | Bandar Abbas, Iran | Cross-sectional study | Women who gave birth at a tertiary hospital | 8,888 |
Among the 15 studies that investigated the relationship between residence and adverse birth outcomes, PTB, perinatal death, and LBW were the most commonly reported adverse birth outcomes. The results indicated that residing in rural areas increased the risk of experiencing all nine selected adverse birth outcomes (i.e., LBW, PTB, SGA, perinatal death, stillbirth, neonatal death, LGA, CS, and miscarriage). Meanwhile, the risks of PTB and CS delivery were found to be higher in urban areas. These findings suggest that the impact of residence on adverse birth outcomes varies; living in rural areas is generally associated with increased risks across multiple outcomes, while urban areas may exhibit specific risks for PTB and CS delivery (Table 5).
| Adverse birth outcomes | Increased risk, rural | Increased risk, urban | No difference |
|---|---|---|---|
| Low birthweight | Bailey et al. (2009) Auger et al. (2009) Mengesha et al. (2017) | Hillemeier et al. (2007) | |
| Preterm birth | Bailey et al. (2009) Shan et al. (2018) Amjad et al. (2019) Woday et al. (2019) Mehrnoush et al. (2023) | Auger et al. (2009) | Hillemeier et al. (2007) Lisonkova et al. (2011) |
| Small for gestational age | Auger et al. (2009) | ||
| Perinatal death | Lisonkova et al. (2011) Li et al. (2018) Mboya et al. (2020) | ||
| Stillbirth | Lisonkova et al. (2011) Bhusal et al. (2019) | Ahinkorah et al. (2021) | |
| Neonatal death | Amjad et al. (2019) | ||
| Large for gestational age | Lisonkova et al. (2011) Amjad et al. (2019) | ||
| Cesarean section | Amjad et al. (2019) | Khanal et al. (2016) Tarimo et al. (2020) | |
| Miscarriage | Ahinkorah et al. (2021) |
Low birth weight (LBW). Three studies63,64,71) reported a higher risk of LBW in rural versus urban areas. Auger et al.63) reported that the risk of LBW was greater in rural areas than in urban areas (OR 1.11, 95% CI 1.05–1.17). Bailey and Cole64) also observed that infants born to women from rural counties had an average weight that was 700 grams less, and an average height 1.5 inches shorter, compared with those born to women from urban counties, with the former being 4.5 times more likely to be LBW than the latter.64) In a study by Mengesha et al.,71) a higher rate of LBW was observed in rural areas (62%) compared with urban areas (59%). The relative risk ratio (RRR) also indicated an increased risk of LBW in rural areas (RRR 0.53, CI: 0.32–0.9) than in urban areas.71) Collectively, these results demonstrate that LBW is more prevalent in rural areas, and that the risk of rural women having LBW infants is higher compared with that of their urban counterparts.
Preterm birth (PTB). Five studies17,62,64,72,74) indicated a higher risk of PTB in newborns in rural areas compared with those in urban areas. One study reported that women from rural areas with low socioeconomic status had an increased risk of CS (OR 1.39, 95% CI 1.19–1.62) than women from urban areas with high socioeconomic status.62) Infants born to women from rural communities were born more than three weeks earlier and were four times more likely to be preterm compared with those born to women from urban communities.64) The risk of PTB was higher in rural women,17,74) especially among those of advanced age.72) On the other hand, Auger et al.63) found a marginal association between an increased risk of PTB and living in urban areas, suggesting that this association may be linked to higher levels of maternal stress experienced by women in urban settings as compared with rural settings. These findings indicate that the risk of PTB is elevated in women from rural areas and may also increase depending on the level of maternal stress.
Small for gestational age (SGA). One study found an association between SGA births and living in rural areas (OR 1.11, 95% CI 1.05–1.17).63) The same study suggested that the increased risk of SGA in rural areas could be attributed to lifestyle factors, such as a higher prevalence of tobacco use in rural areas than in urban areas. Moreover, challenges in accessing antenatal care in rural areas may contribute to the higher risk of SGA.63) These results indicate that SGA is more common in rural areas due to differences in maternal lifestyle and healthcare access between rural and urban areas.
Perinatal death. Perinatal death rates were higher in rural areas than in urban areas.68,69,70) The risk of perinatal death was found to be increased in women from rural areas (OR 1.5, 95% CI 1.1–2.1),69) and moreover, those with preeclampsia had an elevated risk of perinatal death (OR 1.70, 95% CI 1.05–2.74).68) The risk of perinatal death was significantly higher in deliveries of mothers residing in rural areas versus urban areas (RR 1.241, 95% CI 1.137–1.355).70) These results indicate that perinatal death is more common among women residing in rural areas, especially those who experience preeclampsia during pregnancy, than among those residing in urban areas.
Stillbirth. Comparisons between rural and urban areas have revealed higher rates of stillbirth in rural areas.65,69) Women from rural areas were found to have an increased risk of stillbirth than those from urban areas (OR 1.5, 95% CI 1.1–2.1).69) Similarly, Bhusal et al.65) reported a higher likelihood of women from rural areas to experience stillbirth (AOR 1.31, 95% CI 1.00–1.72) compared with women from urban areas. Overall, these results show that stillbirths are more common among newborns of mothers from rural areas.
Neonatal death. Adolescent women with low socioeconomic status in urban areas had an increased risk of neonatal death (OR 2.62, 95% CI 1.01–6.81).62) This suggests that neonatal deaths are more common in urban areas, especially among women with low socioeconomic status.
Large for gestational age (LGA). One study reported a higher rate of LGA in rural areas (16.9%) than in urban areas (14.9%).69) Women from rural areas were also reported to have an increased risk of having LGA infants.62,69) These results show that LGA is more common in newborns of mothers residing in rural areas.
Cesarean section (CS). One study reported a significant difference (P<0.001) in the rate of CS delivery, with urban areas having a four-fold higher rate (23.0%) compared with rural areas (5.8%).67) Similarly, Tarimo et al.73) reported a higher CS rate in urban areas (59.79%) than in rural areas (40.21%). While both studies noted the increased risk of CS delivery in women from urban areas compared with those from rural areas,67,73) another study reported that the risk of CS delivery was increased among adolescent women in rural areas with low socioeconomic status (OR 1.39, 95% CI 1.19–1.62) compared with their urban counterparts.62) These results demonstrate that, while CS delivery remains more common among women in urban areas, its risk is also increased in vulnerable populations in rural areas.
Miscarriage. One study reported a higher miscarriage rate in rural areas (11.1%) than in urban areas (10.4%).61) Women from rural areas had a higher risk of experiencing miscarriage than those from urban areas (AOR 1.14, 95% CI 1.01–1.29),61) suggesting that miscarriages are more common in rural areas than in urban areas.
This scoping review synthesized the literature on adverse birth outcomes in rural and urban areas in 15 studies for the last 18 years. Disaggregated by residence and adverse birth outcomes among women from rural and urban areas, the number of studies pertaining to increased adverse birth outcome risk in urban areas was small. Although we noted heterogeneous associations, women from rural areas were at increased risk of more adverse birth outcomes, and adverse birth outcomes were more prevalent in women residing in rural areas than in those residing in urban areas. The findings of this review support the association of residence with adverse birth outcomes.
We compared nine commonly reported adverse birth outcomes, including LBW, PTB, SGA, perinatal death, stillbirth, neonatal death, LGA, CS, and miscarriage in rural and urban areas. Among these outcomes, PTB was the most frequently reported adverse outcome in rural areas.17,62,64,72,74,78) PTB is the leading cause of mortality in children younger than five years,56) as premature birth interferes with lung maturity and results in underdeveloped fetal lungs, leading to respiratory disorders.79) This is why surviving preterm infants often face challenges in neurodevelopment and cognitive abilities80) and may exhibit behavioral and emotional difficulties later in life.81)
Various maternal risk factors, such as young maternal age, short birth intervals, inadequate antenatal care, poor nutrition, and risky behaviors (drinking alcohol, tobacco use, smoking, and use of prohibited drugs), contribute to PTB.7,82,83) In addition, chronic health conditions such as increased blood pressure, diabetes mellitus, anemia in pregnancy, obesity, maternal HIV status, and sexually transmitted infections are also contributing factors.82,84,85) Among these factors, adolescent pregnancy,86) short birth intervals,87) inadequate antenatal care,88) and poor nutrition89) may explain the increased risk of PTB among rural women, given that rural areas tend to have inadequate maternal healthcare services. However, one study63) found PTB to also be prevalent in urban areas, which may be related to characteristics such as a higher level of perceived stress90,91) and exposure to air pollution and environmental toxins among women in urban areas,92) as these factors were identified as risk factors for adverse birth outcomes.16,93)
LBW remains a significant public health concern with several short- and long-term adverse health outcomes.94) Moreover, it is associated with other adverse birth outcomes such as prematurity95) and SGA.96,97,98) LBW can result from PTB or SGA,97) being attributable to conditions common in rural settings such as iron deficiency or low uptake of antenatal iron supplementation.99) Taking supplements such as iron and folic acid is crucial for fetal growth and development100) because they provide additional nutrients that cannot be supplied by a regular diet.101) However, these supplements may not be as easily accessible in rural areas as they are in urban areas, where women have better access to health facilities. Promoting the antenatal use of iron and folic acid supplements will lead to better intrauterine growth and development of the fetus for the prevention of LBW and SGA, especially among women in rural areas.
Premature birth, a prevalent public health issue in rural communities,44) is an independent risk factor of LBW102) which influences the significantly more than 20 times greater mortality risk of LBW newborns.103) The pathophysiology of LBW is insufficiently understood102,104) but is associated with complications such as asphyxia, insufficient physical growth, and dysfunction in the respiratory system and metabolism, which potentially increase the risk of infectious disease and malnutrition during childhood,105) i.e., a significant factor for low survival probability of LBW infants.106) Therefore, implementing intervention strategies to prevent PTB in rural areas is important for the reduction of LBW, paving the way to better newborn health and survival.
Previous studies have reported that LBW, PTB, and SGA are adverse birth outcomes associated with inadequate antenatal care.107,108,109,110) Inaccessibility of antenatal care is common in rural areas,111,112,113) which may explain the increased risk of adverse birth outcomes in rural communities, as compared with urban areas where health facilities are more readily available. Insufficient antenatal care services have been linked to poor wealth status and a lower level of empowerment of women in rural communities.114) To address these challenges, adopting online and telemedicine platforms in delivering antenatal care services is critical. Moreover, to ensure that women living in rural areas are well-informed and empowered in their decision-making, rural community health workers and health volunteers in remote and rural areas can be mobilized to deliver health information through health education and counseling on maternal healthcare services.
High pre-pregnancy body mass index, pre-existing and gestational diabetes mellitus, a history of previous LGA birth, and significant weight gain during pregnancy are well-known risk factors associated with LGA.115,116,117,118,119) Insufficient or delayed antenatal care, a common issue in rural areas, can lead to inadequate management of maternal health conditions such as gestational diabetes or obesity, which have been linked to the development of LGA newborns.120) Limited access to healthy and nutritious food options in rural areas121) may contribute to a higher prevalence of poor maternal health, and excessive maternal weight gain can contribute to fetal overgrowth and subsequent birth of LGA newborns.118,122) Rural areas often face challenges in accessing health information from primary providers or medical specialists and use of search engines.123) This may result in pregnant women not receiving adequate information about the importance of antenatal care, healthy lifestyles during pregnancy, and the implications of maternal health conditions such as obesity and diabetes, thereby leading to higher rates of LGA newborns in rural areas. The larger fetal size in LGA pregnancies can pose difficulties during labor and increase the likelihood of CS delivery, as well as prolonging hospital strays,124) which explains the associations between LGA and an increased rate of CS delivery and longer hospital stay.125) Therefore, efforts to prevent LGA may contribute to reducing the rate of CS delivery—a surgical obstetrical intervention that increases the risk of maternal and neonatal morbidity and mortality.126,127)
Miscarriage has both physical consequences such as infection and psychological repercussions including anxiety, sadness, post-traumatic stress disorder, and suicide.16) Recurrent miscarriage increases the risk of future obstetric complications, including PTB, fetal growth restriction, placental abruption, and stillbirth, and predicts longer-term health problems such as cardiovascular disease and venous thromboembolism.16) Maternal smoking,128) substance abuse during pregnancy,129) and adolescent pregnancy,86) which are common demographic characteristics in rural areas, have been associated with miscarriages.130,131,132) Therefore, improving healthcare access, promoting awareness about antenatal care, and addressing risk factors can all contribute to reducing the prevalence of miscarriages in rural areas.
Our synthesis of the literature revealed significant associations between preconception health and adverse birth outcomes in specific residential areas. Although mechanisms underlying these relationships are unclear, it is likely that a combination of demographic, maternal, and environmental factors interacting with each other increases the risk of adverse birth outcomes in pregnant women. While the importance of preconception health and access to optimal antenatal healthcare services is recognized, it is crucial not to underestimate the significance of considering the type of residence when assessing and evaluating antenatal care for pregnant women. This review highlights the importance of health information and access to healthcare facilities, particularly in rural communities. By providing pregnant women with comprehensive health information and ensuring adequate access to antenatal care services and specialized care, they can be well-informed about promoting a healthy pregnancy and receiving the support they need.
This systematic review provides evidence that adverse birth outcomes, such as PTB, LBW, SGA, perinatal death, stillbirth, neonatal death, LGA, CS, and miscarriage, are more prevalent in rural areas than in urban areas. These findings underscore the importance of ensuring access to health information, antenatal care services, and healthcare facilities for women in rural communities throughout the entire continuum of pregnancy. Effective interventions should focus on delivering health education and counseling to address the specific challenges faced by rural communities, aiming to improve maternal health outcomes. It is crucial to address maternal risk factors, enhance healthcare accessibility, promote preconception health, and disseminate accurate health information to bridge healthcare disparities between rural and urban areas. By striving for equitable access and outcomes, we can work toward achieving better maternal and neonatal health outcomes for all.
The authors would like to express their gratitude to the Department of Public Health, College of Health Sciences, Kaohsiung Medical University, Taiwan for supporting this research.
EBFD conceptualized and wrote the initial manuscript draft. EBFD and IDS conducted the literature search, study selection, and data extraction. EBFD was responsible for analyzing and interpreting the data. EBFD, FWL, and CDLR wrote the final manuscript. EBFD and IDS revised the manuscript to make important changes in content. All authors have read and approved the final version the manuscript for submission.
The authors declare no conflicts of interest.
