Loss of Obstetric Services in Rural Counties Associated With Childbirth Risks

In rural counties not adjacent to urban areas, the loss of hospital-based obstetric services was associated with more out-of-hospital and preterm births, according to a new study published in JAMA.¹

Rural counties in the United States have experienced a decline in the availability of hospital-based obstetric services, dropping from 55% of counties having these services in 2004 to 46% in 2014. This loss may “exacerbate maternal health challenges” in rural areas, where, compared with urban areas, there are already higher rates of pregnancy-related hospitalizations, low birth weight, and infant mortality.

“Rural counties vary considerably in their proximity to urban centers, and the consequences of loss of hospital-based obstetric services may differ based on adjacency to an urban area,” the authors explained. “Distinguishing rural counties based on adjacency to urban areas, this study examined the relationship between losing hospital-based obstetric services and location of childbirth and birth outcomes.”

The researchers analyzed nearly 5 million births in 1086 rural US counties using data from the 2004-2014 Natality Detail Data maintained by the National Center for Health Statistics. There were 3 primary outcomes: out-of-hospital birth, hospital births in counties without any hospitals providing obstetric care, and preterm birth.

From 2004 to 2014, 179 rural counties lost their hospital-based obstetric services. Women in these counties were more likely to be white and less likely to have a college or graduate degree compared with women in rural counties that did not lose obstetric services. Of the 179 counties, 103 were considered urban-adjacent rural counties.

After analyzing the data, the researchers found that the out-of-hospital birth rate changed from 1.2% in non—urban-adjacent counties to 1.6% the year following loss of hospital-based obstetric services. In urban-adjacent counties, there was a smaller increase in the rate from 1.3% to 1.5%. There were also significant increases in the rate of births in hospitals without obstetric care from 0.4% the year before services loss to 2.47% following services loss in non–urban-adjacent counties. Again, urban-adjacent counties reported a smaller increase, from 0.01% to 1.88%.

“Altogether, the results of this study indicate significant changes in birth location and outcomes immediately following rural obstetric unit closures, with sustained changes over time in rural counties that are not adjacent to urban areas,” the authors concluded. “Such changes may affect clinical care in an already-challenging context.”

In an accompanying editorial,² Neel T. Shah, MD, MPP, of Harvard Medical School and Beth Israel Deaconess Medical Center, wrote that the study provides an indication of how the loss of obstetric services combined with “geographic isolation” is affecting families in rural counties. Loss of services may mean traveling long distances during pregnancy to seek care.

“Among high-income countries, this burden on birthing families is unique to the United States,” wrote Shah.

References

1. Kozhimannil KB, Hung P, Henning-Smith C, Casey MM, Prasad S. Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the United States [published online March 8, 2018.] JAMA. doi: 10.1001/jama.2018.1830.

2. Shah NT. Eroding access and quality of childbirth care in rural US counties [published online March 8, 2018.] JAMA. doi: 10.1001/jama.2018.1646.