Maternal morbidity and perinatal outcomes in rural versus urban areas
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* Stefan Grzybowski
* Jude Kornelsen

We commend Lisonkova and colleagues for the breadth of morbidities they included in their article.1 However, we are disappointed and somewhat astonished over the absence of any attempt to include an analysis of a crucial variable in the discussion: distance to services. This limitation not only weakens the conclusions of the study, but also calls into question the validity of the findings.

The authors note, “The limitations of our study include the lack of individual information on the time needed to travel to the nearest health care facility....” Although individual information would be ideal, all we need to know is whether birthing women have access to maternity services in their community. This lack of service-level consideration undermines the article. There is strong evidence from British Columbia and internationally that local access to maternity care is an important influence on maternal newborn outcomes.

This lack of attention to distance creates a conceptual shortcoming: the rural group has been defined by its isolation from population centres (i.e., maternity health services), but distance to services (predictor of outcomes) is ignored in the cohort analysis. From previous work with an overlapping data set, we predict that of the 25 855 rural cases, between 4000 and 6000 will be from communities that are more than one hour from the nearest maternity services. This could easily account for the relatively minor differences in the odds ratios for the three principal morbidities (eclampsia, obstetric embolism and uterine scar dehiscence/rupture).

Once distance to services is accounted for, data from BC and Canada show that women from communities without maternity services have poorer outcomes than those from communities with services. Data also show that women from communities with primary maternity care (i.e., no cesarean delivery) and communities where cesarean delivery is provided by family physicians with enhanced surgical skills have outcomes as good as those from communities with obstetricians providing care. To suggest, as the authors do in their conclusion, that in rural communities “the emphasis should remain on monitoring” for those conditions “requiring advanced obstetric and neonatal care” is not only misguided, but also impugns the excellent maternity services being provided in communities that are still offering services.

We question why *CMAJ* published this manuscript. It is a weak cohort analysis that ignores the key health services determinants of outcomes for rural maternity care, but then makes recommendations about the organization of health services. The article presents misleading and potentially frightening data for women in rural areas who are trying to decide where they should give birth. A worthwhile adjustment to the analysis of this data would be to stratify those women according to whether they have a local maternity service in their community, and then examine morbidities. The literature has already demonstrated good outcomes for newborns. We expect that data will show the same for maternal outcomes.

## Reference

1.  Lisonkova S, Haslam MD, Dahlgren L, et al. Maternal morbidity and perinatal outcomes among women in rural versus urban areas. CMAJ 2016;188:E456–65.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxNDoiMTg4LzE3LTE4L0U0NTYiO3M6NDoiYXRvbSI7czoyNzoiL2NtYWovMTg4LzE3LTE4LzEyNjEuMS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=)