Outcomes in pregnant patients with congenital heart disease by rurality

To examine the association between rurality, major adverse cardiac events (MACE), adverse pregnancy outcomes (APO) and neonatal outcomes in pregnant women with CHD (congenital heart disease).

A retrospective cohort study using the HCUP-NIS database (Healthcare Cost and Utilization Project-National Inpatient Sample) from 2016 to 2021 was conducted with pregnant CHD patients by location of residence (urban vs. rural). Primary outcomes were MACE, APO and neonatal outcomes. Multivariate logistic regression with survey procedures and weighted odds ratios was used to represent national estimates.

The weighted sample represented 24,295 (n=4,859) patients, of which 20,840 (n=4168) were in urban setting and 3,455 (n=691) lived rurally. Only 27 % (n=185/691) of rural patients accessed care at a rural hospital. Rurality was associated with lower odds of APO (adjusted-OR 0.76; 95 %-CI 0.63-0.91; p=0.003). Rural patients with complex CHD had the lowest odds of APO. There was no statistically significant difference, by rurality, in odds of MACE (adjusted-OR 1.17; 95 %-CI 0.98-1.40; p=0.09) or neonatal outcomes (adjusted-OR 0.78; 95 %-CI 0.59-1.03; p=0.082). There was no effect modification of rurality by CHD complexity on the association between rurality and MACE (p-value=0.66), APO (p-value=0.60) or neonatal outcomes (p-value=0.75).

In this national cohort, pregnant patients with CHD living in rural areas had decreased odds of APO and no significant difference in MACE or neonatal complications. Notably, the majority of rural CHD patients received care in urban hospitals, suggesting referral patterns may mitigate outcome disparities. These findings highlight the need for further research on access, delivery of care, and outcomes for rural patients with CHD, and underscore the importance of ensuring multidisciplinary cardio-obstetric care across geographic settings.