ORIGINAL ARTICLE Birth Outcomes Among Older Mothers in Rural Versus Urban Areas: A Residence-Based Approach Sarka Lisonkova, MD, PhD; 1,2 Samuel B. Sheps, MD, PhD; 3 Patricia A. Janssen, PhD; 2,3 Shoo K. Lee, MD, PhD, MBBA; 4 Leanne Dahlgren, MD, MPH; 1 & Ying C. MacNab, PhD 3 1 Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada 2 Child and Family Research Institute, Vancouver, British Columbia, Canada 3 School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada 4 Department of Paediatrics, University of Toronto, Ontario, Canada Funding: Western Regional Training Centre for Health Services Research, Canada; Michael Smith Foundation for Health Research, Canada; and Canadian Institutes of Health Research. We would like to thank all people who have contributed to the BC PHP perinatal data collection and management. We also thank Serena Howlett, JD, MPH, for reviewing the manuscript. For further information, contact: Sarka Lisonkova, MD, PhD, Child and Family Research Institute, Children’s and Women’s Health Centre, E400-4480 Oak St. Vancouver, Canada V6A 3V4; e-mail slisonkova@cfri.ca. doi: 10.1111/j.1748-0361.2010.00332.x Abstract Purpose: We examined the association between rural residence and birth out- comes in older mothers, the effect of parity on this association, and the trend in adverse birth outcomes in relation to the distance to the nearest hospital with cesarean-section capacity. Methods: A population-based retrospective cohort study, including all single- ton births to 35+ year-old women in British Columbia (Canada), 1999-2003. We compared birth outcomes in rural versus urban areas, and between 3 dis- tance categories to a hospital (<50, 50-150, >150 km). Outcomes included labor induction, cesarean section, stillbirth, perinatal death, preterm birth (<37 weeks), small-for-gestational-age, large-for-gestational-age, and neona- tal intensive care unit admission. We used multivariate regression to obtain adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Findings: Among the 29,698 subjects, 11.5% lived in rural areas; 5% lived within 50-150 km; and 1.1% lived >150 km from a hospital. Rural women were at lower risk of primary and repeat cesarean section (OR = 0.9, CI: 0.9-1.0; OR = 0.7, CI: 0.6-0.9) and small-for-gestational-age (OR = 0.8, CI: 0.7-0.9) births; they were at increased risk for perinatal death (OR = 1.5, CI: 1.1-2.1) and large-for-gestational-age (OR = 1.1, CI: 1.1-1.2) births. The association was stronger among multiparous versus primiparous women. No differences in emergency cesarean section, preterm birth, or neonatal intensive care admission were found, regardless of parity. Perinatal mortality increased with distance from hospital; OR = 1.5 (CI: 1.1-2.1) per distance category. Conclusions: Older women in rural versus urban areas had a lower rate of ce- sarean section and increased risk of perinatal death. The risk of perinatal death increased with the distance to hospital. Further studies need to evaluate the contribution of underlying perinatal risks, access to care, and decision making regarding referral and transport. Key words access to care, birth outcomes, epidemiology, rural, utilization of health services. Delayed childbearing has become an increasingly com- mon phenomenon in the developed world. Advanced maternal age (35+ years) is associated with higher rates of pregnancy complications, obstetric interventions, and an elevated risk of adverse birth outcomes. 1-6 Older women are more likely to have chronic diseases, such as hypertension and diabetes, and pregnancy complications requiring medical intervention, such as placenta pre- via, abruptio placentae, or postpartum hemorrhage. 7-11 Thus, adequate access to appropriate obstetric care is The Journal of Rural Health 27 (2011) 211–219 c  2010 National Rural Health Association 211