Racial Disparities in Respectful Maternity Care During Pregnancy and Birth After Cesarean in Rural United States

Objective: To describe the experiences of pregnancy and birth after cesarean of women who live in rural areas of the United States, including access to vaginal birth after cesarean (VBAC), type of maternity care provider, travel times, autonomy in decision making, and respectful maternity care. Design: Retrospective observational study. Setting: Online questionnaire of women who gave birth in the United States. Participants: Women (N = 1,711) with histories of cesarean and subsequent births within 5 years of participating. Methods: We calculated descriptive and bivariate statistics by identified areas of residence and stratified measures of autonomy and respectful maternity care by self-identification as a member of a racialized group. We applied qualitative descriptive analysis to responses to an open-ended survey question. Results: A total of 299 (17.5%) participants identified their areas of residence as rural. Similar percentages of rural and metropolitan participants were able to plan VBAC (p =.88). More rural participants than metropolitan participants reported travel times of more than 60 minutes to give birth (p <.001), and fewer had obstetricians (p =.002) or doulas (p =.03). Rural participants from racialized groups experienced significantly less respectful maternity care than White, non-Hispanic rural participants and all metropolitan participants (p =.04). Qualitative data illustrating the main findings are included. Conclusions: Our findings highlight challenges faced by rural residents accessing VBAC and help explain why rates of VBAC in rural areas remain low. We suggest a range of clinical and policy strategies to improve access to VBAC in rural areas and to improve the quality of maternity care for racialized women who live in rural areas.