Hospital obstetric units and entire facilities are closing in rural areas across the country leaving residents with increasingly limited options for care. A new School of Public Health study quantifies those closures, finding that nine percent of rural counties in the U.S. lost hospital-based childbirth services from 2004-14. During this time, rural counties without hospital-based obstetric services increased from 45 to 54 percent, which means that more than half of rural counties across the nation no longer have a hospital where a woman can give birth.
“Until now, we didn’t have data to illustrate the true scale of the recent decline in these services,” says Peiyin Hung, a recent doctoral graduate of the School of Public Health and lead author of the study. “The decreasing access to maternity care for reproductive age women living in rural America is concerning.”
The study appears in the September issue of Health Affairs.
Hung, Associate Professor Katy Kozhimannil, and researchers Carrie Henning-Smith and Michelle Casey, all with the University’s Rural Health Research Center, analyzed multiple national data sources to evaluate changes in the availability of obstetric services among 1,249 rural hospitals located in 1,086 rural counties across the country between 2004-14.
In addition to the 179 counties that lost childbirth services, the research also found that another 45 percent of rural counties had no hospital obstetrics services at all during the decade studied.
“When you see declining access to childbirth services alongside rising rates of maternal morbidity and mortality, it’s clear that this is a systems-level issue that must be addressed,” says Kozhimannil.
The study found that rural counties with higher proportions of black women and those counties with lower median household incomes had higher odds of losing all hospital obstetric services, as did rural counties in states with less generous Medicaid eligibility criteria for pregnant women.
“This study reveals rural communities that bear disproportionate risk of lacking local options for childbirth care. These include rural black communities, medically underserved areas, low-income areas, and rural residents of states with more restrictive Medicaid policies,” says Kozhimannil. “Providing adequate geographic access to obstetric care in vulnerable and underserved rural communities is a challenge, and it will require creative federal, state, and local solutions as well as innovative policies and partnerships.”
The challenges facing rural communities require comprehensive solutions that address the unique needs of different settings. The researchers encourage policymakers to engage in meaningful conversations with rural communities about potential options to create the best path forward, including using telemedicine technologies; developing regional perinatal networks to encompass maternal care; and providing transportation services for rural pregnant women without local access.
“Striking a balance between access to childbirth care without having to travel a substantial distance and ensuring sufficient volume of service for the maintenance of clinician skills and financial viability is difficult and imprecise,” says Kozhimannil. “Our findings show that these conversations need to happen to ensure communities that are already socioeconomically disadvantaged are not facing compounding challenges in accessing necessary care.”