Nearly half (45%) of rural counties in the United States had no hospitals with obstetric services from 2004 to 2014, new research shows, and of those that did, 9% lost all obstetric services during that decade.
Peiyin Hung, a PhD candidate in the University of Minnesota School of Public Health, Minneapolis, and coauthors used American Hospital Association data to look at 1249 rural hospitals in 1086 rural counties and found a great disparity in access to obstetric care among rural areas.
They defined loss of services as complete closure of a hospital with an obstetric unit or closure of the obstetric unit in a hospital that was still open.
Lower-income counties and those with higher percentages of black women and states that had lower income thresholds for Medicaid eligibility for pregnant women were the most likely to lose obstetric services, according to the study, published online September 5 in Health Affairs.
“[B]lack women and Medicaid beneficiaries in rural areas have less access to nonlocal high-acuity obstetric care than do white or privately insured rural women — even when black women and those on Medicare have high-risk clinical conditions (such as preterm or multiple births) that may warrant advanced care in urban hospitals,” the authors write.
Additionally, states have very different income thresholds for Medicaid eligibility. The authors explain that in 2017 that range was from 138% to 380% of the federal poverty level. Rural families with similar incomes may not have the same access to insurance if they live across a state border from each other.
The implications are far reaching because more than 28 million women of child-bearing age in the United States live in rural areas and nearly half a million women each year give birth in rural hospitals, the authors point out.
Women in rural areas already have poorer outcomes in many categories than their counterparts in urban areas.
The authors explain that rates of postpartum hemorrhage and of blood transfusions in labor and delivery are higher in rural areas. Maternal and infant mortality rates in the most rural regions are significantly higher than for women in large, urban settings.
Extensive travel may contribute to higher risk for infant mortality and pregnancy complications, and, according to the study, more than half of rural women must travel more than 30 minutes to reach an obstetrician compared with 7% of their urban counterparts.
Traveling even farther distances means potentially worse outcomes, the authors note.
“All maternal and infant deaths are tragic; those related to impaired access to care are abhorrent,” they write.
Some states were particularly hard hit by closures. In North Dakota and South Carolina, 20% of rural counties lost obstetric services in their hospitals during the study period.
Advances in telemedicine may be one promising solution, the authors note. That would help rural patients with high-risk or specialty needs connect immediately with a provider without having to travel if the services have been shut down locally.
“Such technologies may give low-volume rural hospitals ready access to referral, consultation, and outreach education from larger regional hospitals so that skills and patient safety can be maintained locally,” they write.
The authors have disclosed no relevant financial relationships.
Health Aff. Published online September 5, 2017. Abstract
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