A new study from theUniversity of Minnesota School of Public Health found that access to obstetric care across the country has declined, and that those closures have hit rural communities the hardest.
New data includes the four years from 2018 to 2022, when the national policy designed to preserve obstetrics units was already in place.
The study looked at the status of obstetric services between 2010 and 2022 in nearly 5,000 short-term, acute care hospitals in all 50 states and the District of Columbia. Using an enhanced algorithm, the researchers determined whether hospitals stopped providing obstetric services over the 12-year period, and whether those hospitals were in urban or rural areas.
Seven states saw nearly a quarter of their hospitals close their obstetric units, the researchers found. By the end of 2022, two-thirds of rural hospitals in eight states were without obstetric services. In Pennsylvania, South Carolina, West Virginia, and Florida, more than 40% of rural hospitals lost obstetrics services. Declines in care disproportionately affected rural hospitals in highly rural states (those where more than 30% of the population lives in rural areas). For example, in North Dakota, 73% of hospitals lacked obstetrics by 2022, and 63% of Oklahoma hospitals lacked obstetrics.
“We have been [looking at access to obstetrics care] for a long time, and this study period is updated from our previous work, that looked through 2018,” Katy Backes Kozhimannil, lead author and professor at the University of Minnesota School of Public Health, said in an interview with the Daily Yonder.
“And 2018 was when we passed the Improving Access to Maternity Care Act. What we are seeing is that in spite of a lot of policy dialogues that happened in the late 2010s and early 2020s, we’re still seeing this trend happening. The analysis we published is the first time that we’ve looked at this by state and been able to distinguish patterns of closures for rural and urban hospitals.”
The results varied between states, she said. Some states — such as Delaware, Utah, and Vermont — did not see any closures during the study period, while others (Iowa, West Virginia, and Oklahoma) had more than a quarter of their hospitals stop providing obstetrics during the same time frame.
“We know that there are differences between rural and urban folks, and that what a rural or urban area looks like is very different in Kansas than in Massachusetts, and in Oregon than it is in Florida. This data and study present another look at the trends that allows for each state and their distinctive environments to be visible.”
Overall, access to obstetric care is eroding in both rural and urban communities, she said, which is occurring alongside a maternal health crisis as state health policies are changing rapidly. Lack of access to care, though, can endanger both the baby and the mother.
“Obstetric unit closures can increase distance to care and put pregnant patients and newborns at risk,” Kozhimannil said. “Our analysis revealed wide variability across states in obstetric care losses and highlighted the growing access challenges faced by people living in rural communities and highly rural states.”
Previous research, she said, found that in states that chose to expand Medicaid, there were delays in closing obstetrics units, but it did not stop the units from shutting down.
“Medicaid is such an important payer in rural healthcare, and it's obviously like the top payer for births in rural areas and across the US,” she said. “Medicaid and Medicaid financing and Medicaid policy are very important. But a Medicaid policy like Medicaid expansion, which focuses on the low-income childless adult population, was not targeted enough to specifically affect the financing for rural maternity care. It obviously did help hospital finances a lot. But that help… was not targeted toward the obstetric service line, which is in and of itself problematic, and why financing obstetric care in rural areas is tough.”
Dr. Eileen Thrower, department chair for Frontier Nursing University’s Department of Midwifery and Women’s Health, said the lack of access to obstetrics in rural communities has been increasing since she started nursing in 1990. That has led those patients in rural communities to turn to alternatives for prenatal and postpartum care.
“I think we're seeing more and more telehealth being done in rural areas,” Thrower said in an interview with The Daily Yonder. “I do think we're seeing an uptick in more midwives and more nurse practitioners. I mean, obviously, those are very much growing fields, particularly on the nurse practitioner side. But in terms of maternity care, the problem is that midwives are often going to be located where they can do births in a hospital. And if a hospital or a labor and delivery unit has closed in a rural area, midwives don't tend to be able to stay there because they also can't do the birth.”
That lack of access to delivery services can negatively impact the health of mothers and their children.
“I'm afraid the impact that we see and that we know is documented is that in rural settings, folks are less likely to be able to receive adequate prenatal care which is really tied to poorer outcomes,” Thrower said. “And they're also then traveling further for birth, which is, if you've got to drive an hour or two or more to get to the hospital, things can happen on that travel. There's more risk there.”
A study in Obstetrics & Gynecology published this month in “Obstetrics & Gynecology” found that residents in a “maternity care desert” are more likely to have a higher rate of maternal and pregnancy-related death.
The study found that maternal health outcomes in the U.S. rose 89% since 2018 because of structural inequities in health care access - particularly in rural and underserved areas.
“A key determinant of maternal health is the availability of qualified maternity care practitioners, including obstetricians, gynecologists, and certified nurse–midwives,” the study found. “Previous studies suggest that adequate access to these practitioners improves outcomes such as preterm birth, preeclampsia, and neonatal outcomes. Their uneven distribution has created gaps in care, with up to 40% of rural counties lacking maternity care practitioners.”
For policy makers, that means addressing how rural hospitals are paid for maternity care, and how to fund a service in a hospital that isn’t needed 24/7 like an emergency department would be, Kozhimannil said.
While efforts have been made to address the financial aspect of maternity units, the results of her research show those efforts have not yet worked, she said. Her research indicates that policy makers need to focus on getting rural hospital administrators what they say they need – nurses and anesthesiologists who can do cesarean deliveries, family physicians who can do obstetrics, telehealth support for low-birth volume hospitals, and other high-cost items.
Maternity care is a service that is necessary, but not well reimbursed, she said, and in rural areas with a heavy reliance on Medicaid for financial support, continuing to fund that service can be a difficult decision for hospital administrators to make.
“It’s hard for hospitals to invest more resources into that service line, whether that's recruitment and retention or training or telemedicine networks. For policy makers, the solutions really need to be targeted toward maternity care financing to ensure access to and preservation of maternity care access.”
This article first appeared on The Daily Yonder and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.