Reducing Rates of Cesarean Delivery in Rural US Communities: A Systematic Review of Interventions and Approaches to Care

Clinical Snapshot

Key Findings

• P Value: Not reported

• Effect Size: Psychosocial education: 21% vs 40% cesarean rate (intervention vs control); mobile health application: 27.1% vs 27.7% (marginal, non-significant difference); family medicine-led hospitals vs mixed FM/OB staffing: 23% vs 28% NTSV cesarean rate; certified nurse-midwife-managed vs family medicine physician-managed births: 8% vs 14%; collaborative maternity care model: 26.2% declining to 11.2%

• Primary Outcome: Cesarean delivery rates in rural US settings, stratified by intervention type (patient-level vs system-level)

• Nnt Or Sensitivity: NNT cannot be calculated from reported data due to absence of confidence intervals and statistical testing. Descriptive absolute risk differences range from approximately 0.6 percentage points (mobile health app) to approximately 19 percentage points (psychosocial education), but these are unadjusted and uncontrolled estimates from individual studies

• Confidence Interval: Not reported for any included study findings in the review

Clinical Application

System-level interventions (midwifery integration, family medicine-led models, collaborative care teams) are feasible in rural settings with appropriate workforce planning and training investment. Patient-level interventions such as psychosocial education are low-cost and scalable but show variable effect. Mobile health applications showed minimal benefit in this context. Implementation requires sustained health system investment, rural workforce development, and culturally responsive care design. Australia faces analogous challenges in rural and remote maternity care, with rising cesarean rates in regional hospitals and significant workforce shortages. The findings are directionally relevant to Australian policy: the RACGP and Australian College of Midwives both support collaborative maternity care models in rural settings. Midwifery-led continuity of care models are supported by Australian evidence (e.g., Cochrane reviews on midwife-led continuity models) and are partially funded through state health systems. The TGA does not regulate care models, but workforce credentialing and scope-of-practice frameworks (AHPRA) govern midwifery and GP-led obstetric care in Australia. PBS considerations are not directly applicable to this intervention type. The National Maternity Services Plan and the work of the Australian Centre for Rural and Remote Medicine (ACRRM) provide relevant policy frameworks. Caution is warranted in direct extrapolation given differences in rural classification, healthcare financing, Indigenous health contexts, and medicolegal environments between the US and Australia. Pregnant individuals in rural or regional communities with limited access to specialist obstetric services, particularly those at low risk (nulliparous, term, singleton, vertex presentations) where unnecessary cesarean delivery is most amenable to prevention

Abstract

INTRODUCTION: Cesarean deliveries are the most common major surgery in the US, with rates rising disproportionately in rural communities. While sometimes medically necessary, unnecessary cesarean births increase risks for maternal death, long-term complications, and intergenerational health effects that contribute to the burden of chronic disease. This systematic review examined studies describing interventions and approaches to care that reported outcomes related to reducing cesarean delivery rates in rural US communities. METHODS: We searched 4 databases in September 2025. Studies were eligible if they were conducted in rural US settings and reported cesarean-related outcomes associated with an intervention or care approach. We categorized interventions as patient level, provider level, or health system level. Two reviewers independently screened articles for inclusion, extracted data, and assessed study quality using the Newcastle-Ottawa Scale and the Joanna Briggs Institute checklist. RESULTS: Nine studies met inclusion criteria. Of the 2 patient-level interventions, psychosocial education was associated with lower cesarean delivery rates (21% in intervention vs 40% in control), whereas a mobile health application showed only a marginal difference (27.1% among application users vs 27.7% among nonusers). None were categorized at the provider level. Seven interventions tested system-level models, primarily comparing hospitals with different staffing patterns; family medicine-led hospitals had lower rates of low-risk nulliparous, term, singleton, vertex cesarean delivery than hospitals staffed by both family medicine physicians and obstetricians (23% vs 28%), certified nurse-midwife-managed births had lower cesarean delivery rates than family medicine physician-managed births (8% vs 14%), and collaborative maternity care models integrating midwives, nurses, and obstetricians were associated with cesarean delivery rates declining from 26.2% to 11.2%. CONCLUSION: System-level approaches, particularly those that restructure maternity care teams, emphasize family medicine physician-led models, and integrate midwifery and culturally grounded childbirth practices, are more consistently associated with lower cesarean delivery rates in rural US settings than patient-level interventions alone. Future efforts to reduce unnecessary cesarean deliveries should prioritize strategies tailored to the variability of rural care capacity.

References

1. 1.Funakoshi, J. L., Collins-Doijode, H. M., & Braun, K. L. (2026). Reducing rates of cesarean delivery in rural US communities: A systematic review of interventions and approaches to care. Preventing Chronic Disease. https://doi.org/10.5888/pcd23.260039