Rural Counties Continue to Lose Obstetric Services, Raising Concerns About Access

A new study finds that obstetric units are closing at a concerning rate in rural American counties, highlighting the need to ensure access to obstetric care for vulnerable women.

The study, published in the new issue of Health Affairs, used 5 unique databases to characterize recent trends in obstetric services closures in rural counties, which are home to more than 28 million women of childbearing age. The authors explain that evidence points to trends of hospital and emergency department closures in rural areas, as well as reduced obstetric access and poorer birth outcomes among rural women, but their research is the first to examine the factors associated with obstetric unit closures in rural US counties from 2004 to 2014.

Each rural country was characterized by the status of hospital obstetric services available during the study period: no services, meaning the county never had in-hospital obstetric services; continual services, if at least 1 hospital in the county had such services; and full closure, if all hospital obstetric services in the county had closed. The researchers identified potential covariates, like county sociodemographic and economic characteristics, as well as demand-side and supply-side factors indicating the number of women of reproductive age and obstetric healthcare providers, respectively.

During the period of 2004 to 2014, 45% of rural hospitals did not have any hospitals with obstetric services at any point, and 9% saw all of their county’s hospital obstetric services shuttered, meaning that 2.4 million women of reproductive age lived in counties with no such services available.

“Noncore” rural counties were significantly more likely to have no hospital obstetric services or to lose these services during the study period than micropolitan rural counties containing an urban core of at least 10,000 but fewer than 50,000 residents. In 2004, 59% of noncore rural counties not adjacent to an urban county had no hospital obstetric services, and by 2014 that proportion had increased to 69%.

The likelihood of never having a hospital with obstetric services was higher in counties in the lowest quartile of birth volume and with higher percentages of non-Hispanic black women of reproductive age. These odds were lower in counties with more women, more healthcare providers, higher median household income, and higher Medicaid income eligibility thresholds for pregnant women.

“This highlights the disproportionate barriers that rural women in vulnerable communities face in gaining access to hospital obstetric services,” the study authors wrote. They noted that these barriers could worsen the existing racial and income disparities in obstetric care and maternal and infant outcomes.

Citing their finding about Medicaid eligibility thresholds, the authors recommended that these disparities may be addressed by providing more rural women with Medicaid coverage, thus enabling hospitals to keep their obstetrics units open. If obstetrics closures cannot be avoided, tools like telemedicine can help providers monitor pregnant women in rural areas.

“The substantial decline in county-level availability of hospital-based obstetric services in rural areas raises concerns about rural women’s access to maternity care,” the researchers concluded. They also wrote that the observed racial and income disparities “should raise concerns that counties that may already be socioeconomically disadvantaged face compounding challenges in ensuring access to necessary care.”