Decline in Hospital-Based Obstetric Services Seen Across US States

Hospital-based obstetric services have declined significantly across the US over the past decade, according to a study published in Health Affairs.¹ The trend is especially pronounced in rural areas, where closures can leave large portions of the population without ready access to labor and delivery care.

Obstetric care access is a key determinant of maternal and infant health, the authors explained, and the loss of these services can adversely affect care access and outcomes. In recent decades, the US has seen a trend of increasing maternal mortality, which stands out among trends of declining pregnancy-related deaths in other high-income countries.²

Overall, hospital-based obstetric care was most lacking in North Dakota, Oklahoma, West Virginia, Louisiana, South Dakota, and Mississippi. | Image credit: BJP7images - stock.adobe.com

“The burden of maternal morbidity and mortality in the US varies across states, and rising rates have occurred alongside a decline in obstetric care access, particularly in rural areas,” the authors of the new study wrote.¹ “During the past 2 decades, rural counties experienced persistent losses of hospital-based obstetric services, with losses disproportionately affecting the most remote, rural areas of the US.”

Researchers analyzed data from 4964 short-term, acute-care hospitals between 2010 and 2022. Overall, obstetric care losses varied substantially between states, with Delaware, Utah, and Vermont experiencing no obstetric service losses from 2010 to 2022. However, in some states, obstetrics services at more than a quarter of hospitals previously offering them were closed. These included Iowa; Oklahoma; Pennsylvania; Rhode Island; South Carolina; Washington, DC; and West Virginia.

Both rural and urban areas lost obstetric services, with more than 25% of all hospitals losing obstetric services in 7 states: Iowa (33.3%); West Virginia (30.0%); Washington, DC (28.6%); Rhode Island (28.6%); Pennsylvania (27.7%); South Carolina (26.9%); and Oklahoma (26.2%). More than two-thirds of rural hospitals lacked obstetrics services in 8 states—Alabama, Florida, Illinois, Mississippi, Nevada, North Dakota, Oklahoma, and West Virginia.

There were significant differences in the losses of obstetric care in rural vs urban hospitals, the authors noted. Regarding rural counties, those in Pennsylvania, South Carolina, West Virginia, Florida, and Iowa had the highest percentage of hospitals that lost obstetric services, ranging from 39.7% in Iowa to 46.2% in Pennsylvania. In comparison, the highest percentages of hospitals that lost obstetrics in urban areas—Washington, DC; and urban counties in Kansas; Rhode Island; Oklahoma; and Hawaii—ranged from 28.6% to 30.4%.

“Although obstetric unit closures can consolidate care at higher-acuity facilities, the loss of these units can increase distance to care for pregnant patients and eliminate obstetric care access for large geographic areas," the authors wrote. “Greater distances to care are associated with maternal morbidity and adverse infant outcomes. Impacts of these closures may be particularly acute for rural residents who are also lower income and those who bear higher risks for maternal and infant morbidity and mortality.”

The percentage of rural hospitals without obstetrics was highest in Florida (87.0%), North Dakota (81.1%), and West Virginia (70.4%). In South Dakota (72.7%) and Hawaii (62.5%), the percentage of urban hospitals without obstetrics was highest.

Overall, hospital-based obstetric care was most lacking in North Dakota (73.3%), Oklahoma (63.4%), West Virginia (62.3%), Louisiana (60.3%), South Dakota (60.0%), and Mississippi (60.0%). Notably, many of these states are rural. The greatest differences in rural vs urban obstetric care losses were in New Hampshire (36.4% in rural, 0% in urban), Florida (40% in rural, 11.8% in urban), South Carolina (46.2% in rural, 20.5% in urban), and Pennsylvania (46.2% in rural, 22.1% in urban)

“Access to obstetric care is an important determinant of maternal and infant health outcomes, and in a time of maternal health crisis in the US, hospital-based obstetric services have declined across most states and in both rural and urban communities,” the authors concluded. “These findings could inform state-specific, targeted planning and policy efforts to address declining obstetric care access and associated maternal and infant health outcomes in rural and urban US communities.”

References

1. Kozhimannil KB, Hung P, Henning-Smith C, Casey M, Thomas SR. Decline in hospital-based obstetric services in the United States, 2010-22. Health Aff (Millwood). 2024;43(7). doi:10.1377/hlthaff.2024.01552
2. Collier AY, Molina RL. Maternal mortality in the United States: updates on trends, causes, and solutions. Neoreviews. 2019;20(10):e561-e574. doi:10.1542/neo.20-10-e561