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Figure.  Number of Rural US Counties With Hospital Obstetric Care, 2014-2018
Number of Rural US Counties With Hospital Obstetric Care, 2014-2018
Table.  Changes in Obstetric Service Availability Among Urban and Rural Counties and by Rural County Type, 2014-2018
Changes in Obstetric Service Availability Among Urban and Rural Counties and by Rural County Type, 2014-2018
1.
Hung  P, Henning-Smith  CE, Casey  MM, Kozhimannil  KB.  Access to obstetric services in rural counties still declining, with 9 percent losing services, 2004-14.   Health Aff (Millwood). 2017;36(9):1663-1671. doi:10.1377/hlthaff.2017.0338PubMedGoogle ScholarCrossref
2.
Kozhimannil  KB, Hung  P, Henning-Smith  C, Casey  MM, Prasad  S.  Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the United States.   JAMA. 2018;319(12):1239-1247. doi:10.1001/jama.2018.1830PubMedGoogle ScholarCrossref
3.
Kozhimannil  KB, Interrante  JD, Henning-Smith  C, Admon  LK.  Rural-urban differences in severe maternal morbidity and mortality in the US, 2007-15.   Health Aff (Millwood). 2019;38(12):2077-2085. doi:10.1377/hlthaff.2019.00805PubMedGoogle ScholarCrossref
4.
Ely  DM, Driscoll  AK, Matthews  TJ.  Infant mortality rates in rural and urban areas in the United States, 2014.   NCHS Data Brief. 2017;(285):1-8.PubMedGoogle Scholar
5.
Hung  P, Kozhimannil  KB, Casey  MM, Moscovice  IS.  Why are obstetric units in rural hospitals closing their doors?   Health Serv Res. 2016;51(4):1546-1560. doi:10.1111/1475-6773.12441PubMedGoogle ScholarCrossref
Research Letter
July 14, 2020

Changes in Hospital-Based Obstetric Services in Rural US Counties, 2014-2018

Author Affiliations
  • 1University of Minnesota Rural Health Research Center, University of Minnesota School of Public Health, Minneapolis
JAMA. 2020;324(2):197-199. doi:10.1001/jama.2020.5662

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.

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).

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.
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Article Information

Corresponding Author: Katy B. Kozhimannil, PhD, MPA, Division of Health Policy and Management, University of Minnesota, 420 Delaware St, SE MMC 729, Minneapolis, MN 55455 (kbk@umn.edu).

Accepted for Publication: March 30, 2020.

Author Contributions: Dr Kozhimannil and Ms Interrante had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Kozhimannil, Interrante.

Critical revision of the manuscript for important intellectual content: Interrante, Tuttle, Henning-Smith.

Statistical analysis: Interrante.

Obtained funding: Kozhimannil, Henning-Smith.

Administrative, technical, or material support: Kozhimannil, Tuttle, Henning-Smith.

Supervision: Kozhimannil.

Conflict of Interest Disclosures: None reported.

Funding/Support: We gratefully acknowledge funding support from the Federal Office of Rural Health Policy, Health Resources and Services Administration, US Department of Health and Human Services (cooperative agreement U1CRH03717-13).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Hung  P, Henning-Smith  CE, Casey  MM, Kozhimannil  KB.  Access to obstetric services in rural counties still declining, with 9 percent losing services, 2004-14.   Health Aff (Millwood). 2017;36(9):1663-1671. doi:10.1377/hlthaff.2017.0338PubMedGoogle ScholarCrossref
2.
Kozhimannil  KB, Hung  P, Henning-Smith  C, Casey  MM, Prasad  S.  Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the United States.   JAMA. 2018;319(12):1239-1247. doi:10.1001/jama.2018.1830PubMedGoogle ScholarCrossref
3.
Kozhimannil  KB, Interrante  JD, Henning-Smith  C, Admon  LK.  Rural-urban differences in severe maternal morbidity and mortality in the US, 2007-15.   Health Aff (Millwood). 2019;38(12):2077-2085. doi:10.1377/hlthaff.2019.00805PubMedGoogle ScholarCrossref
4.
Ely  DM, Driscoll  AK, Matthews  TJ.  Infant mortality rates in rural and urban areas in the United States, 2014.   NCHS Data Brief. 2017;(285):1-8.PubMedGoogle Scholar
5.
Hung  P, Kozhimannil  KB, Casey  MM, Moscovice  IS.  Why are obstetric units in rural hospitals closing their doors?   Health Serv Res. 2016;51(4):1546-1560. doi:10.1111/1475-6773.12441PubMedGoogle ScholarCrossref
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