Abstract
This study describes hospital-based obstetric service losses in rural US counties between 2014 and 2018 overall and by county population and urban adjacency.
In 2014, 54% of rural US counties had no hospital-based obstetric services, following a steady decline over the prior decade.1 Loss of rural maternity care is associated with adverse maternal and infant health outcomes. Rural counties that have lost hospital-based obstetric services experienced higher rates of emergency department births, and in rural counties not adjacent to urban areas, increases in preterm birth, a leading cause of infant mortality.2
Risks of infant and maternal mortality are elevated for rural residents,3,4 highlighting the importance of clinical and policy efforts to ensure rural obstetric care access. The purpose of this study was to describe hospital-based obstetric service losses in rural US counties from 2014 to 2018.
Methods
Data came from the 2014-2018 American Hospital Association (AHA) annual survey, the Centers for Medicare & Medicaid Services’ Provider of Services File, and the Area Health Resources File. Consistent with prior research, annual hospital obstetric service status was identified using AHA hospital-reported factors: provision of obstetric services, at least level 1 status for maternity care, at least 1 dedicated obstetric bed, and at least 10 births per year.1,2 Hospitals were classified as having obstetric services each year if they reported all AHA factors or 1 factor and as having obstetric services in the Provider of Services File; discrepancies were verified via hospital website searches.
Hospitals within rural (nonmetropolitan) counties were placed into 4 categories based on county population (micropolitan, with a town of 10 000-50 000, and noncore, without a town >10 000) and urban adjacency. We categorized county-level obstetric services into 3 groups: (1) no services, (2) continual services, and (3) change in obstetric service availability. This was a descriptive, county-level analysis using SAS version 9.4 (SAS Institute Inc).
Results
This study included 6233 hospitals (2041 rural and 4192 urban hospitals) in all 3145 US counties (1976 rural and 1169 urban counties). Obstetric service losses were concentrated in rural US counties; among urban counties, there was a slight net gain in counties with hospital-based obstetric services. From 2014 to 2018, 53 rural counties (2.7%) lost hospital-based obstetric services, in addition to the 1045 counties (52.9%) that never had obstetric services during the study period (Table). Obstetric service losses were most frequent in rural noncore counties (3.5% overall lost services), where the proportion that never had obstetric services throughout 2014 to 2018 was already high (68.7% of counties). These losses in rural noncore counties included 3 counties with hospital closures and 52 counties where hospitals remained open but closed their obstetric units.
Table. Changes in Obstetric Service Availability Among Urban and Rural Counties and by Rural County Type, 2014-2018.
| No. (%)a | ||||||
|---|---|---|---|---|---|---|
| Counties | Rural county type | |||||
| All urban (n = 1169) | All rural (n = 1976) | Micropolitan | Noncore | |||
| Urban-adjacent (n = 384) | Non–urban-adjacent (n = 272) | Urban-adjacent (n = 644) | Non–urban-adjacent (n = 676) | |||
| Never had hospital(s) with obstetric services | 431 (36.9) | 1045 (52.9) | 68 (17.7) | 70 (25.7) | 453 (70.3) | 454 (67.2) |
| Obstetric services | ||||||
| Continual | 657 (56.2) | 844 (42.7) | 300 (78.1) | 195 (71.7) | 166 (25.8) | 183 (27.1) |
| Gain | 48 (4.1) | 17 (0.9) | 6 (1.6) | 2 (0.7) | 4 (0.6) | 5 (0.7) |
| Loss | 33 (2.8) | 70 (3.5) | 10 (2.6) | 5 (1.9) | 21 (3.3) | 34 (5.0) |
| Relative change in obstetric service availability (gain minus loss)b | 15 (1.3) | −53 (−2.7) | −4 (−1.0) | −3 (−1.1) | −17 (−2.6) | −29 (−4.3) |
The percentages in each column add to 100% across the categories of never having had obstetric services, continual services, gain of obstetric services, and loss of obstetric services.
The category of relative change in obstetric service availability represents counties that gained obstetric services minus those that lost obstetric services among all counties within each county type.
From 2014 to 2018, 1.0% (n = 4) of micropolitan urban-adjacent and 1.1% (n = 3) of micropolitan non–urban-adjacent counties lost hospital-based obstetric services, while 2.6% (n = 17) of rural noncore urban-adjacent and 4.3% (n = 29) of rural noncore non–urban-adjacent counties lost services. Changes in the number and proportion of counties with hospital-based obstetric services from 2014 to 2018 indicate the steepest declines among noncore non–urban-adjacent counties and a net gain in services among urban counties (Figure).
Figure. Number of Rural US Counties With Hospital Obstetric Care, 2014-2018.
Discussion
Findings reveal 2 major patterns in hospital-based obstetric care in rural US counties. First, the least populated rural areas adjacent to urban areas (noncore urban-adjacent counties) were least likely to have local obstetric services. Second, the least populated, most remote rural counties (noncore non–urban-adjacent counties) experienced the greatest reduction in obstetric service availability during 2014 to 2018. A greater proportion of micropolitan rural counties (with a town of at least 10 000) had and retained obstetric services.
Counties vary in size, and some hospital service areas cross county borders. Use of county as the unit of analysis is an important limitation, as is the lack of clinical data on outcomes of service loss and sociodemographic and community data.
Obstetric service losses are concentrated in the most remote rural areas. Staffing and financial concerns are frequently cited reasons for ceasing obstetric services,5 and obstetric unit closure is more common in rural counties with lower average incomes and fewer births.1 Clinical and policy efforts to ensure local obstetric care access must account for variable patterns of service loss across rural US communities.
Section Editor: Jody W. Zylke, MD, Deputy Editor.
References
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