Does telehealth narrow the urban-rural gap? A dual assessment of in-person and telehealth prenatal care accessibility

Telehealth has been proposed to reduce rural prenatal care barriers, but its equity effects depend on whether predicted accessibility translates into observed utilization. We examine whether predicted and revealed in-person and telehealth prenatal care accessibility diverge across the urban-rural continuum of South Carolina and whether these measures align with ZIP Code Tabulation Area (ZCTA)-level birth-related need, measured as average annual live births by residence. Using Medicaid claims data for 2020–2021, predicted accessibility was estimated using floating catchment area methods, with the telehealth specification incorporating broadband availability and subscription constraints; revealed accessibility was operationalized as observed prenatal visit volume within 30-min catchments across 424 ZCTAs. Urban-rural differences were assessed with Mann-Whitney U tests, and associations with birth volume were examined using spatial lag and spatial error models. Predicted in-person accessibility did not differ significantly between urban and rural ZCTAs (p = .67), whereas revealed in-person accessibility was significantly lower in rural areas (p < .001), indicating that predicted opportunity did not translate uniformly into observed utilization. Both predicted and revealed telehealth accessibility also showed significant urban-rural disparities (p < .001), with 36.76% of rural ZCTAs recording zero predicted telehealth accessibility compared with 7.53% of urban ZCTAs. These findings show that telehealth expanded potential access but operated within existing in-person care networks and did not equalize access. Improving rural prenatal care access will therefore require stabilizing in-person obstetric capacity, strengthening digital infrastructure, and supporting provider adoption of telehealth.