Access to obstetric care in rural communities is critical to ensuring good maternal and child health outcomes. Eighteen million reproductive-age women live in America’s rural counties, but over half of these counties have no hospital where people who are pregnant can give birth. The past decade has been marked by a decline in maternity care access, as hospitals and obstetric units across rural America shutter their doors.
[Photo: Dr. Katy Kozhimannil]
Now, the consequences of these closures are becoming clear in a new study authored by two University of Minnesota School of Public Health researchers and published in the Journal of the American Medical Association. Associate professor Dr. Katy Kozhimannil and assistant professor Dr. Carrie Henning-Smith, who lead the University’s Rural Health Research Center, examined how birth outcomes change after losing obstetric services, focusing on two categories of rural counties — those located next to an urban area (urban-adjacent) and the more remote rural areas not located near an urban area (non-adjacent).
The research found that families living in non-urban-adjacent rural counties faced increased risk of out-of-hospital birth, birth in a hospital that does not provide obstetric care (possibly in an emergency department), and preterm birth, after losing hospital-based obstetric services.
“Preterm birth is the leading cause of infant mortality, and infant mortality is higher in rural versus urban communities,” said lead author Dr. Kozhimannil. “Loss of hospital-based obstetric services has immediate and significant impacts on rural families, and may exacerbate the challenges rural mothers and families already face.”
The findings revealed the biggest effects of the loss of hospital-based obstetric care were seen in the most remote rural counties (i.e., those that were not adjacent to urban areas). Before services loss, approximately one percent of births occurred out of the hospital, less than half a percent of births occurred in hospitals without obstetric services, and 12 percent of babies were born preterm. After losing hospital-based obstetric care, residents of rural counties not adjacent to urban areas experienced an increase in out-of-hospital births (0.70 percentage points), births in hospitals without obstetric units (3.06 percentage points), and preterm births (0.67 percentage points), compared to counties with continual obstetric services.
“These findings should raise concern about immediate and long-term health impacts for mothers and babies, especially in the most remote rural areas, which already experience disproportionate economic and health challenges,” said Dr. Henning-Smith, co-author of the study.
In urban-adjacent rural counties, there was an increase in births in hospitals without obstetric services (1.80 percentage points), followed by a decline over time.
“After local hospitals stopped doing obstetrics or closed entirely, rural communities far from urban areas saw a rise in conditions that may put moms and babies at risk — including birth in a hospital with no obstetric capacity as well as preterm birth,” said Dr. Kozhimannil. “Knowing the consequences of services loss, policymakers, clinicians, and families can make informed choices to help ensure the safety and well-being of rural moms and babies.”