Obstetric Care Access at Rural and Urban Hospitals in the United States

Abstract

This study quantifies losses and gains of obstetric care services at US rural and urban short-term acute care hospitals between 2010 and 2022.

Access to obstetric care has been declining in the US, while maternal mortality is rising.^1,2 Loss of hospital-based obstetric services can adversely affect perinatal care quality and outcomes.³ Maternal and infant morbidity and mortality and care access barriers are elevated for rural residents and racially minoritized people.^2,4,5 There are no peer-reviewed national data on hospital-based obstetric care access after 2018, when several national maternity care access initiatives began.^1,5 This study quantifies losses and gains of obstetric care at rural and urban short-term acute care hospitals between 2010 and 2022.

Methods

This retrospective cohort study included all US short-term acute care or obstetrics/gynecology specialty hospitals. Using American Hospital Association (AHA) annual surveys and Centers for Medicare & Medicaid Services Provider of Services (POS) files from 2010 to 2022, we applied an enhanced algorithm to identify availability of hospital-based obstetric services annually for each hospital.^1,6

First, we assessed obstetric status using 4 AHA variables (reported provision of obstetric services; ≥level 1 obstetric care; ≥1 dedicated obstetric bed; and ≥10 births per year) and 1 or more POS-indicated obstetric clinician. Second, we checked and corrected obstetric unit status inconsistencies over time, including cases of hospital mergers and acquisitions, for which we decoupled consolidated AHA identification numbers to follow hospitals over time. Any remaining inconsistencies were further verified with phone calls, review of hospital websites, and news sources per the algorithm process.⁶

Hospital rurality was classified using Office of Management and Budget definitions. Urban hospitals were located in metropolitan statistical areas (counties with ≥1 urbanized area of ≥50 000 inhabitants); rural hospitals were located in non–metropolitan statistical areas (counties without an urbanized area of ≥50 000 inhabitants).

Among rural and urban hospitals, we assessed the losses and gains of obstetric services from 2010 to 2022, calculating the percentage of hospitals without obstetrics among hospitals open during the indicated year. This was a descriptive, hospital-level analysis; SAS software version 9.4 was used. This study was exempted by the University of Minnesota Institutional Review Board; informed consent did not apply.

Results

This study included 4964 short-term acute care hospitals (1982 in rural counties and 2982 in urban counties). In 2010, 43.1% (843/1955) of rural hospitals and 29.7% (836/2813) of urban hospitals did not offer obstetric care (Table). Each subsequent year, there was a net loss of obstetric services at US hospitals. Between 2010 and 2022, there were 537 hospitals that lost obstetrics, split between rural hospitals (238) and urban hospitals (299). During this time, 138 hospitals gained obstetrics, concentrated heavily among urban hospitals (112) vs rural hospitals (26). In 2022, 52.4% of rural hospitals and 35.7% of urban hospitals did not offer obstetric care.

Table. Changes in Hospital-Based Obstetric Service Availability at US Short-Term Acute Care Hospitals, 2010-2022.

Year	No. of short-term acute care hospitals					Hospitals without obstetrics, %d
	Totala	Hospitals without obstetricsa	Hospitals with obstetricsa	Hospitals that gained obstetricsb	Hospitals that lost obstetricsc
National, all hospitals
2010	4768	1679	3089			35.2
2011	4769	1706	3063	16	42	36.7
2012	4758	1719	3039	22	46	37.1
2013	4752	1735	3017	19	41	37.4
2014	4732	1744	2988	15	44	37.8
2015	4716	1749	2967	19	40	37.9
2016	4712	1777	2935	9	41	38.6
2017	4707	1806	2901	9	43	39.3
2018	4676	1815	2861	8	48	39.8
2019	4655	1841	2814	10	57	40.8
2020	4645	1884	2761	13	66	42.0
2021	4650	1916	2734	17	44	42.2
2022	4639	1934	2705	3	32	42.4
Totale	4964	1722	2567	138	537
Rural hospitals
2010	1955	843	1112			43.1
2011	1955	864	1091	2	23	45.4
2012	1953	878	1075	4	20	46.0
2013	1945	885	1060	4	19	46.5
2014	1932	885	1047	3	16	46.6
2015	1916	880	1036	6	17	46.8
2016	1912	893	1019	2	19	47.7
2017	1907	906	1001	1	19	48.5
2018	1888	910	978	2	25	49.5
2019	1873	920	953	1	26	50.5
2020	1866	935	931	2	24	51.4
2021	1865	945	920	3	14	51.4
2022	1860	957	903	0	17	52.4
Totalf	1982	841	877	26	238
Urban hospitals
2010	2813	836	1977			29.7
2011	2814	842	1972	14	19	30.6
2012	2805	841	1964	18	26	30.9
2013	2807	850	1957	15	22	31.1
2014	2800	859	1941	12	28	31.7
2015	2800	869	1931	13	23	31.9
2016	2800	884	1916	7	22	32.4
2017	2800	900	1900	8	24	33.0
2018	2788	905	1883	6	23	33.3
2019	2782	921	1861	9	31	34.2
2020	2779	949	1830	11	42	35.7
2021	2785	971	1814	14	30	35.9
2022	2779	977	1802	3	15	35.7
Totalg	2982	881	1690	112	299

^a Numbers are total hospitals open and operating as short-term acute care hospitals, those without obstetrics, and those with obstetrics within the indicated year.

^b Numbers are hospitals without obstetrics in the previous year but with obstetrics in the indicated year.

^c Numbers are hospitals with obstetrics in the previous year but without obstetrics in the indicated year (either because the hospital closed their obstetric unit or because the hospital itself closed).

^d Percentage of hospitals without obstetrics is the number of hospitals that lost obstetrics (column 6) added to the number of hospitals without obstetrics (column 3) divided by the total number of short-term acute care hospitals (column 2) in that year.

^e Among the total 4964 hospitals open and operating as short-term acute care hospitals in any year during 2010-2022 in the US, 1722 never had an obstetric unit during that time, 2567 had obstetric services in 2010 and 2022 (2560 had continuous obstetric services; 7 had a period within those years when the obstetric unit was closed), 138 gained obstetric services during 2011-2022, and 537 lost obstetric services (522 had an obstetric unit in 2010 and lost it during 2011-2022; 15 gained obstetric services after 2010 but then lost those services by 2022).

^f Among the total 1982 rural hospitals open and operating as short-term acute care hospitals in any year during 2010-2022, 841 never had an obstetric unit during that time, 877 had obstetric services in 2010 and 2022 (876 had continuous obstetric services; 1 had a period within those years when the obstetric unit was closed), 26 gained obstetric services during 2011-2022, and 238 lost obstetric services (235 had an obstetric unit in 2010 and lost it during 2011-2022; 3 gained obstetric services after 2010 but then lost those services by 2022).

^g Among the total 2982 urban hospitals open and operating as short-term acute care hospitals in any year during 2010-2022, 881 never had an obstetric unit during that time, 1690 had obstetric services in 2010 and 2022 (1684 had continuous obstetric services; 6 had a period within those years when the obstetric unit was closed), 112 gained obstetric services during 2011-2022, and 299 lost obstetric services (287 had an obstetric unit in 2010 and lost it during 2011-2022; 12 gained obstetric services after 2010 but then lost those services by 2022).

There was a steady rise in the percentage of hospitals without obstetrics in 2010-2022, increasing from 35.2% to 42.4% of all hospitals (Figure). The percentage of hospitals without obstetrics was higher among rural hospitals compared with urban hospitals in each year.

Figure. Percentage of US Short-Term Acute Care Hospitals Without Obstetric Care, 2010-2022.

Percentages are shown based on the total number of short-term acute care hospitals each year (2010-2022), where the numerator is comprised of all hospitals without obstetrics (including those that lost obstetrics) in a given year and the denominator is the total number of hospitals operating in that year. Denominators in 2010 were 4768 (national), 1955 (rural), and 2813 (urban). Denominators declined due to hospital closures, and in 2022, were 4639 (national), 1860 (rural), and 2779 (urban).

Discussion

Between 2010 and 2022—a time of tremendous attention to maternal health⁵—there was a net loss of hospital-based obstetric care in both rural and urban hospitals across the US. In 2010, more than half of rural hospitals and two-thirds of urban hospitals offered obstetric care. Rural hospitals started with lower percentages of hospitals offering obstetrics compared with urban hospitals and experienced a larger increase in the percentage of hospitals without obstetrics.

Study limitations include lack of data on births outside hospital settings (<2% of US births). Furthermore, the denominator for the study outcome declined each year with hospital closures, which were more prevalent among rural hospitals. While rurality is a continuum, we applied a dichotomous county-based measure of hospital location. Also, these descriptive hospital-level data did not contain patient-level information; thus, analysis of how obstetric status changes affected patient outcomes was not feasible.

Access to obstetric care is an important determinant of maternal and infant health outcomes,³ and amidst a maternal health crisis in the US,^2,5 hospital-based obstetric care has declined in both rural and urban communities.

Section Editors: Kristin Walter, MD, and Jody W. Zylke, MD, Deputy Editors; Karen Lasser, MD, MPH, Senior Editor.

Supplement.

Data Sharing Statement