Half of rural SC families bypass local hospitals to deliver their babies in urban settings and experience worse outcomes

Posted on: November 21, 2025; Updated on: November 13, 2025

November 21, 2025 | Erin Bluvas, bluvase@sc.edu

Rural and maternal health expert Peiyin Hung has published new research on maternal health outcomes based on the hospital locations where rural South Carolinians give birth. Published in JAMA Network Open, the health services policy and management (HSPM) associate professor and her co-authors* found that 47% of rural mothers are opting to deliver in urban hospitals over local facilities. These rural residents had higher risks of severe maternal morbidity and mortality.

Rural mothers shouldn’t have to risk their lives to give birth safely. Our findings suggest that not only are rural residents at higher risk for severe maternal morbidity and mortality, but that traveling outside one’s local area for childbirth – whether due to clinician referral, patient choice, or other factors – appears to compound the risk.

Peiyin Hung

“The phrase ‘severe maternal morbidity’ encompasses the different, potentially life-threatening, conditions that can manifest during pregnancy, at delivery, or post-partum,” says Hung, who co-directs the Rural Health Research Center alongside HSPM associate professor Elizabeth Crouch. “These complications are often accompanied by long, expensive hospital stays, long-term psychosocial impacts, and can even result in death. They also disproportionately impact rural populations, who experience mortality rates at two times the levels experienced by their urban peers.”

Many of these disparities are driven by social determinants of health, such as access to care or travel burdens to receive timely specialized care. Despite efforts by Hung and others to demonstrate the importance of local obstetric units and to increase the availability of telehealth services and other alternative treatment methods, access to maternity care has been declining nationwide.

47% of rural mothers are opting to deliver in urban hospitals over local facilities in South Carolina.

Rural America lost nearly one-fifth of its hospital-based obstetric units between 2004 and 2018, compared to a 5% reduction in urban settings. Since 2013, South Carolina has lost 13 of these facilities, and fully half of our 46 counties have been designated as medically underserved areas.

“In the past, rural residents have bypassed local facilities to seek obstetric care in urban hospitals due to complex clinical needs that require more comprehensive, specialized care, and the closures we’ve seen over the past decade or so have exacerbated this trend,” Hung says. “However, until this study, we didn’t have a clear idea of how these mothers were faring in terms of their health outcomes after delivery.”

Peiyin Hung is an associate professor of health services policy and management and co-director of the Rural Health Research Center.

With support from a National Institutes of Health U01 grant, Hung and her team examined the hospital records of 235K+ childbirths that took place in South Carolina between 2018 and 2022. Their analyses revealed that 15% of the deliveries were attributed to rural residents, 6.4% of whom opted to travel to urban hospitals over utilizing local sites – yielding a 47% bypassing rate. Among all of the participants included in the study – urban women, rural women delivering in rural hospitals, and rural women delivering in urban hospitals – the last group faced the highest rates of severe maternal complications and death while the other two groups faced similar risks to each other-even after accounting for clinical and demographic factors.

“Rural mothers shouldn’t have to risk their lives to give birth safely. Our findings suggest that not only are rural residents at higher risk for severe maternal morbidity and mortality, but that traveling outside one’s local area for childbirth – whether due to clinician referral, patient choice, or other factors – appears to compound the risk,” Hung says. “This increased risk for this population highlights the need to strengthen rural maternal health systems in high-risk communities and facilitating care coordination from childbirth delivery through postpartum.”

Arnold School of Public Health

Half of rural SC families bypass local hospitals to deliver their babies in urban settings and experience worse outcomes

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