Background
Pre‐existing diabetes in pregnancy is associated with an increased risk of complications. Likewise, living in rural, regional and remote Victoria, Australia, is also associated with poorer health outcomes. There is a gap in the literature with regard to whether Victorian women with pre‐existing diabetes experience a greater risk of adverse pregnancy outcomes compared to their metropolitan counterparts.

Aim
Our objective is to compare obstetric and perinatal outcomes for women with pre‐existing diabetes delivering in rural vs metropolitan hospitals in Victoria, Australia.

Materials and Methods
Retrospective population‐based study using routinely collected state‐based data of singleton births to women with type 1 and type 2 diabetes who delivered in metropolitan (n = 3233) and rural hospitals (n = 693) in Victoria, Australia, between 2006–2015. Pearson’s χ2 test, Fisher’s exact test and MannWhitney U‐test were used to compare obstetric and perinatal outcomes between metropolitan and rural locations.

Results
Delivery in a rural hospital was associated with higher rates of stillbirth (2.3% vs 1.1%, P = 0.027), macrosomia (25.9% vs 16.9%, P < 0.001), shoulder dystocia (8.4% vs 3.5%, P < 0.001) and admission to the neonatal intensive care unit/special care nursery (73.2% vs 59.3%, P < 0.001). Smoking (18.0% vs 8.9%, P < 0.001), overweight/obesity (P = 0.047) and socioeconomic disadvantage (P < 0.001) were more common in rural women. Conclusions Women with pre‐existing diabetes who deliver in rural hospitals experience a greater risk of adverse perinatal outcomes and present with increased maternal risk factors. These results suggest a need to improve care for women with pre‐existing diabetes in rural Victoria.