Rural counties saw a significant number of obstetric unit closures during the 10-year period ending in 2014, according to a new report, with researchers saying the figures raise concerns about access to care for women of reproductive age.
About 9 percent of rural counties lost hospital-based obstetric services between 2004 and 2014, researchers at the University of Minnesota wrote in the study published this week. The decline means that just over half of all rural counties in the U.S. — roughly 54 percent — lacked hospital-based obstetric units in 2014.
Units for labor and delivery are expensive to operate and don’t always cover their costs, said Katy Kozhimannil, one of the U researchers who published the study in the journal Health Affairs. It also can be difficult for rural hospitals to maintain the professional staff needed for high-quality obstetrics service.
“It’s a difficult financial puzzle for rural hospitals that want to provide these services, but struggle to do so,” Kozhimannil said. “Obstetrics is not known as the most lucrative of service lines among hospitals.”
In a report published earlier this year, U researchers showed a similar rate of decline in rural counties across Minnesota, although the state started with and still maintains a higher share of rural counties with hospital-based obstetric units than the national average.
In the new study, researchers looked at 1,984 rural counties in the United States and found in 2004 a lack of hospital-based obstetric units in 898, or 45 percent, of the total.
By 2014, the number of rural counties lacking hospital-based obstetrics grew by 170 to a total of 1,068 counties, according to the report. Researchers estimate that in 2014 a total of 2.4 million women of reproductive age were living in counties with no in-hospital obstetric service.
Counties with lower median incomes and a greater percentage of non-Latino black women were more likely to lack or lose obstetric services. Another factor, researchers said, is the state-federal Medicaid health insurance program, which covers nearly half of all births in the U.S. and an even greater share of births to rural women.
They cited one report from 2013 showing average total commercial insurer payments for all maternal and newborn care with vaginal delivery was $18,329, compared with $9,131 by Medicaid.
“Medicaid pays about half of what private health plans pay for births,” Kozhimannil said.
Even so, the study found that states like Minnesota and Wisconsin with more extensive eligibility and benefits under Medicaid were more likely to have hospital-based obstetric units in rural counties. North Dakota, by contrast, has tighter eligibility rules for Medicaid coverage and a much lower share of rural counties with hospital-based obstetrics units.
“If you have more people that have health insurance and that are coming into the hospitals ... with a payer, as opposed to self-pay, then that may contribute to the overall financial health of those hospitals,” Kozhimannil said.
In the earlier study, U researchers reported that about 46 percent of all rural counties in the U.S. had hospital-based obstetric services. Wisconsin and Minnesota had relatively high rates at about 70 percent and 67 percent, respectively, while the rate in North Dakota was among the lowest at about 15 percent.
The reports show the factors driving the decline aren’t unique to Minnesota, said Dr. Rahul Koranne, chief medical officer at the Minnesota Hospital Association. For hospitals and their communities, the decision to close an obstetrics unit is a source of “heart ache,” Koranne said, but health systems that elect to do sometimes are concerned about maintaining high-quality programs.
“As we know across the U.S., which is playing out in Minnesota, the pipeline of future clinicians is limited,” Koranne said. “So that’s one thing that health systems have to think about — you do not want to continue the [obstetric] services if you do not have the appropriate staff in place 24/7.”