Obstetric care continues to vanish from rural areas

When rural hospitals go into the red, they often have little choice but to stop delivering babies.

The result can be terrifying. Harrowing roadside births have been documented in news stories and online.

Maternal unit closures that put women and their babies in rural areas at heightened risk of complications and death aren't a new trend. ProPublica covered the dilemma in a 2017 interview with Katy B. Kozhimannil, Ph.D., who co-directs the University of Minnesota's Rural Health Research Center.

Yet seven years on, the situation has not improved much.

"Sadly, in spite of the advancement of research and the increased policy action to address maternity care access, hospitals continue to shutter their obstetric units, year after year," Kozhimannil said in an email.

Nevertheless, there are fresh story angles. More is known about the causes and effects of closures and how to improve patient safety. Research, much of it by Kozhimannil and her team, has advanced on related topics such as structural racism, obstetric safety, and intimate partner violence.

Risky situations

Two new reports describe the extent of closures.

According to the Rural Health Research Center's latest research letter, the percentage of rural hospitals without obstetric care grew from 43.1% in 2010 to 52.4% in 2022. More recent data from the Center for Healthcare Quality and Payment Reform (CHQPR) show that as of November, more than 57% of rural U.S. hospitals did not offer labor and delivery services.

Obstetric closures aren't just inconvenient; longer travel times are associated with riskier deliveries. A 2018 study found that after a rural county loses an obstetric unit, more women have a preterm birth, give birth in a hospital without an obstetric unit or give birth outside of a hospital. (Hence, the roadside births.)

Some closures have been precipitated by a drop in the birthrate, which means less revenue to support obstetric care. As KFF Health News highlighted in a story in July, it's difficult for a hospital to maintain quality when it handles few deliveries.

A 2023 paper bolstered evidence of greater complication rates among women who give birth at low-volume rural hospitals. However, the authors argued that rather than recommend closures, policymakers should provide extra resources to improve quality, increase training, and establish referral networks.

Crippling underpayment

Payers typically don't cover the cost of obstetric care. Meanwhile, round-the-clock staffing expenses have increased, partly because obstetricians and family physicians who can perform c-sections are less willing to be on call, according to CHQPR, which focuses on strategies to achieve affordable, patient-centered care.

Many rural hospitals can no longer offset obstetric losses because they lose money on other services, its report notes. Meanwhile, cost reports indicate that nearly 40% of rural hospitals with labor and delivery services lost money on patient care overall in 2023, putting hundreds of communities at risk of losing obstetric care.

In some areas, obstetric services are under heightened threat as clinicians flee restrictive state abortion laws - a dynamic explored in a Commonwealth Fund report.

Gaining attention

Lawmakers have begun to take notice.

This year a group of Senate Democrats introduced the Keeping Obstetrics Local Act, which would boost Medicaid payments for obstetric services at rural hospitals including "standby" payments for low-volume hospitals. The bill would also require states to study the cost of providing obstetric care.

Meanwhile, private health plans face pressure to boost payments. The Purchaser Business Group on Health, a coalition of large employers, adopted purchasing standards that require "adequate" payments to support convenient access to maternity care, including labor and delivery services at small rural hospitals.

CHQPR President and Chief Executive Officer Harold Miller suggested in an interview that journalists highlight the ongoing financial struggles of rural hospitals before they close an obstetric unit, rather than just covering the aftermath.

Miller advised reporters to ask how much various payers reimburse the hospital for obstetric care - which may evoke surprising information. "Everybody assumes that private insurers pay more than Medicaid, but it's the opposite in many small rural hospitals," Miller said.

Last year NewsChannel 5 in Nashville reported rates that Blue Cross Blue Shield paid for deliveries at Henry County Medical Center in Paris, Tenn. - rates that an ob-gyn at the hospital called so paltry as to be "immoral." The hospital ended up closing its obstetric unit.

Another angle is how hospitals such as Ridgecrest Regional Hospital in California and WVU Medicine Uniontown Hospitals in Pennsylvania buck the trend and manage to reopen their obstetric units.

But, Miller noted, such revivals are not common.

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